LIBRARY OF CONGRESS, 
%^-3- §0wt$t f o> 

UNITED STATES OF AMERICA. 



A MANUAL 



AUSCULTATION AND PERCUSSION 

EMBRACING THE 

PHYSICAL DIAGNOSIS OF DISEASES OF THE LUNGS AND 
HEART, AND OF THORACIC ANEURISM. 



/ 



BY 



AUSTIN FLINT, M.D., LL.D., 



FIFTH EDITION, THOROUGHLY REVISED. 



BY 

J. C. WILSON, M.D., 

LECTURER OS PHYSICAL DIAGNOSIS IN THE JEFFERSON MEDICAL COLLEGE. ETC. ETC. 



ILLUSTRATED WITH WOOD-CUTS. 



/O 




PHILADELPHIA: 

LEA BROTHERS & CO. 

1890. 



9~ 






Entered according to Act of Congress, in the year 1890, by 

LEA BEOTHEKS & CO., 

In the Office of the Librarian of Congress. All rights reserved. 



D R X A ft, P R I X T E R . 



PREFACE TO THE FIFTH EDITION. 



Much of the Author's work, as set forth in the last edition 
of this book, appears to be final ; it requires neither altera- 
tion nor addition. Some of the questions remain to-day, as 
five years ago, unsettled ; nor does the advance of knowledge 
within that period justify any important modifications of the 
statements then made. The value of this manual lies not so 
much in the fact that it contains the results of the original 
investigations of Professor Flint; the profession has made 
them, as part of our common knowledge, its own, and others 
have, with more or less success, incorporated them into com- 
pilations of varying degrees of usefulness. Its value is to be 
discovered in the clearness and appropriateness of its style, 
the accuracy of its statements, its scientific method, and the 
practical treatment of subjects at once difficult and essential 
to the student of medicine. In respect to these qualities it 
stands, and will long stand, alone among the books devoted 
to auscultation and percussion. 

The present revision, undertaken in response to a very 
general demand, will, it is hoped, serve to prolong the 
availability of a work which, while already a medical classic, 
shows no sign of waning in popularity and usefulness among 
teachers and students. The Editor. 

Philadelphia, October, 1890. 



PREFACE TO THE FOURTH EDITION". 



The fact that, within a little over two years, a large 
edition of this manual has been exhausted, is gratifying 
proof of the increased favor with which it is regarded by 
the medical profession. The Author has been thereby incited 
to endeavor to make it still more acceptable by a thorough 
revision. 

The present edition contains some important modifications 
and considerable additions. A notable improvement is the 
introduction of diagrammatic illustrations, which will enhance 
the usefulness of the work. 

jSTew York, October, 1885. 



Figs. 1, 2, 3, and 4 are borrowed, with modifications, from 
Handbuch und Atlas der topographischen Percussion, von 
Dr. Adolf Weil, Professor an der Universitiit Heidelberg. 



PREFACE TO THE THIRD EDITION. 



In the revision of this manual for a third edition, it has 
been deemed advisable, as in the previous editions, to restrict 
its scope to auscultation and percussion considered chiefly 
with reference to their practical application, and to present 
these with as much condensation as possible. In the present 
edition, the modes by which pulmonary signs may be repro- 
duced in the lungs removed from the body, and by artificial 
illustrations, have been briefly stated. The author has also 
introduced some practical points kindly suggested by his 
friend and colleague, Professor Janeway. The speedy ex- 
haustion of the second edition may, perhaps, be fairly 
regarded as evidence, not alone of the usefulness of the 
work to the medical student and practitioner, but of an 
increasing appreciation of the importance of the study of 
auscultation and percussion, as well as of the analytical 
method by which the study is facilitated, and knowledge of 
the physical signs made readily available in diagnosis. 

New York, March, 188:1. 



PREFACE TO THE SECOND EDITION. 



This work contains the substance of the lessons which the 
Author has for many years given, in connection with prac- 
tical instruction in auscultation and percussion, to private 
classes composed of medical students and practitioners. 

In his courses of practical instruction his plan has been, 
1st. To simplify the subject as much as possible, avoiding all 
needless refinements ; 2d. To consider the distinctive char- 
acters of the different physical signs as determined, not by 
analogies, nor by deductions from physics, but by analysis, 
and as based especially on variations in the intensity, pitch, 
and quality of sounds; 3d. To impress the fact that the signifi- 
cance of physical signs relates to certain physical conditions, 
and the importance of a familiar acquaintance with these 
conditions, as well as with the distinctive characters of the 
signs by which they are represented ; 4th. To enforce the 
necessity of sufficient study of the physical conditions and 
the signs of health, as a sine qua noil, for success in the study 
of the physical diagnosis of diseases; and, 5th. To waive dis- 
cussion of the mechanism of signs, whenever this is open for 
discussion, taking the ground that our knowledge of the 



vii l PREFACE TO SECOND EDITION. 

significance of signs rests solely on the constancy of their 
connection with the physical conditions which they represent. 
This plan, of which the utility has been confirmed by con- 
tinned experience, has been followed throughout the present 
volume, and the favor with which the work has been received 
has seemed to show that no radical changes were required. 
In revising it for a second edition, therefore, the Author has 
confined himself to such additions as seemed likely to render 
it more useful, not only to students engaged in the practical 
study of the subject, but also to practitioners as a handbook 
for ready reference. 

New York, January, 1880. 



CONTENTS. 



CHAPTER I. 

INTRODUCTION. 

Definition of percussion and auscultation — The sounds obtained 
by these methods of representing healthy and morbid physical 
conditions — Definition of signs — -The basis of our knowledge of 
signs the constancy of association of certain sounds with certain 
physical conditions in health and disease — The present state of 
perfection of our knowledge of signs furnished by auscultation 
and percussion— Requirements for the successful study of these 
methods of exploration — The anatomy and physiology of the 
chest — An enumeration of the points relating thereto which are 
of especial importance — The physical conditions incident to the 
different diseases of the chest : the conditions relating to the 
respiratory system stated, and a summary of them — The dis- 
tinctive characters of healthy and morbid signs; variations in 
intensity, pitch, and quality, considered as the chief source of 
the characters distinguishing the signs of disease from each 
other and from those of health — Other distinctions than those 
of intensity, pitch, and quality — The analytical method of the 
study of auscultation and percussion— The significance of signs 
as regards the physical conditions which they severally repre- 
sent — Morbid conditions, not individual diseases, represented 
by the morbid signs — Regional divisions of the chest — Anatomi- 
cal relations of the regions severally to the parts within the 
chest 

CHAPTER II. 

PERCUSSION IN HEALTH. 

Percussion with the fingers or with a percussor and pleximeter— 
The normal vesicular resonance on percussion; its distinctive 
character relating to intensity, pitcb, and quality — Variations 



CONTENTS. 



in the characters of the normal vesicular resonance in different 
persons— Relation of the pitch of resonance to the vesicular 
quality — Tympanitic resonance over the abdomen — Variations 
of the normal resonance in the different regions of the chest — 
Enumeration of the regions in which the resonance on the two 
sides varies, and those in which it is identical in health — Influ- 
ence of age on the normal resonance — Influence of the acts of 
respiration on the resonance — Rules in the practice of percus- 
sion 



CHAPTEK III 



PERCUSSION IN DISEASE. 



Enumeration of the signs of disease furnished by percussion — 
Requirements for a practical knowledge of these signs — The 
distinctive characters of the morbid physical conditions repre- 
sented by, and the different diseases into the diagnosis of which 
enter, th-. signs, severally, to wit : 1. Absence of resonance or 
flatness: 2. Diminished resonance; 3. Tympanitic resonance; 
4. Vesiculotympanitic resonance: 5. Amphoric resonance; 6. 
1 r,i -ked-metal resonance — Sense of resistance felt in the prac- 
tice of percussion, as a morbid sign lit 

CHAPTER IV. 

AUSCULTATION IN HEALTH. 

Importance of the study of the auscultatory sounds in health — 
Immediate and mediate auscultation — Advantages of the bin- 
aural stethoscope — Rules to be observed in auscultation — Divi- 
sions of the study of auscultation in health — -The normal 
laryngeal and tracheal respiration — The normal vesicular mur- 
mur; its distinctive characters, and the variations in the 
different regions on the same side, and in corresponding regions 
on the two sides of the chest — The normal vocal resonance — 
The laryngeal and tracheal voice and whisper — The normal 
thoracic vocal resonance and fremitus; the distinctive charac- 
ter- of each: the variations in different regions on the same 
side, and in corresponding regions on the two sides of the chest 
— The normal bronchial whisper, with its variations in different 
regions on the same side, and in corresponding regions on the 
two sides of the chest 73 



CONTENTS. 



CHAPTER V. 



AUSCULTATION IN DISEASE. 

PAGE 



The respiratory signs of disease— Abnormal modifications of the 
normal respiratory sounds: — Increased vesicular murmur — 
Diminished vesicular murmur — Suppressed respiratory sound — 
Bronchial or tubular respiration — Broncho-vesicular respiration 
— Cavernous respiration — Broncho-cavernous respiration — 
Vesiculocavernous respiration— Amphoric respiration — Short- 
ened inspiration — Prolonged expiration — Interrupted respira- 
tion. Adventitious respiratory sounds or rales. Laryngeal or 
tracheal rales — Moist bronchial rales, coarse, fine, and subcrepi- 
tant— Vesicular or crepitant rale — Cavernous or gurgling rale — 
Pleural friction rales, metallic tinkling and splashing — Indeter- 
minate rales. The vocal signs of disease : Bronchophony — 
Whispering bronchophony — iEgophony — Increased vocal reso- 
nance — Increased bronchial whisper — Cavernous whisper — 
Pectoriloquy — Amphoric voice or echo — Diminished and sup- 
pressed vocal resonance — Diminished and suppressed vocal fre- 
mitus — Metallic tinkling. Signs obtained by acts of coughing 
or tussive sounds 94 



CHAPTER VI. 



THE PHYSICAL DIAGNOSIS OF DISEASES OF THE RESPIRATORY 
ORGANS. 

Affections of the larynx and trachea — Bronchitis seated in large 
bronchial tubes — Bronchitis seated in small bronchial tubes, or 
capillary bronchitis — Collapse of pulmonary lobules — Lobular 
pneumonia — Asthma — Pulmonary or vesicular emphysema — ■ 
Pleurisy, acute and chronic — Empyema — Hydrothorax — Pneu- 
mothorax — Pneumo-hydrothorax — Pneumo-pyothorax — Acute 
lobar pneumonia — Circumscribed pneumonia — Embolic pneu- 
monia — Hemorrhagic infarctus — Pulmonary apoplexy— Pulmo- 
nary gangrene — Pulmonary oedema — Carcinoma of lung — 
Tumor within the chest — Acute miliary tuberculosis — Pulmo- 
nary phthisis — Fibroid phthisis, interstitial pneumonia, or 
cirrhosis of lung — Diaphragmatic hernia 14( 



CONTENTS, 



CHAPTEE VII. 

THE PHYSICAL CONDITIONS OF THE HEART IN HEALTH AND 
DISEASE. THE HEART-SOUNDS AND CARDIAC MURMURS. 

PAGE 

Physical condition? of the heart in health : Boundaries of the prse- 
cordia — Normal situation of the apex-beat — Boundaries of the 
deep and of the superficial cardiac space — Relations of the aorta 
and the pulmonary artery to the walls of the chest — The heart- 
sounds— Characters distinguishing the first and the second sound 
— Mechanism of production of the heart-sounds — Auscultation 
of the pulmonic and the aortic second sound separately — Aus- 
cultation of the mitral and tricuspid valvular sounds— Move- 
ments of the auricles and ventricles in relation to each other 
— Physical conditions of the heart in disease : Enlargement of 
the heart— Hypertrophy and dilatation — Abnormal impulses of 
the heart, and modifications of the apex-beat — Valvular lesions 
— Roughness of the pericardial surfaces— Liquid within the 
pericardial sac— Abnormal modifications of the heart sounds- 
Reduplication of heart-sounds— Cardiac murmurs— Normal and 
abnormal blood-currents within the heart, and their relations 
with the heart-sounds— Mitral direct murmur — Mitral regurgi- 
tant murmur — Mitral systolic non-regurgitant, or intra-ventric- 
ular murmur — Mitral diastolic murmur — Aortic direct murmur 
— Aortic regurgitant murmur, and an Aortic diastolic non- 
regurgitant murmur— Coexisting endocardial murmurs— Tricus- 
pid direct murmur — Tricuspid regurgitant murmur — Pulmonic 
direct murmur — Pulmonic regurgitant murmur — Facts of prac- 
tical importance in relation to endocardial murmurs— Pericar- 
dial or friction murmur • . • H'4 

CHAPTEE VIII. 

THE PHYSICAL DIAGNOSIS OF DISEASE OF THE HEART AND 
OF THORACIC ANEURISM. 

Enlargement of the heart by hypertrophy and dilatation — 
Valvular lesions, mitral, aortic, tricuspid, and pulmonic — Fatty 
degeneration and softening of the heart — Endocarditis— Peri- 
carditis — Functional disorders — Thoracic aneurism . . . 239 



MANUAL 

OF 

AUSCULTATION AND PERCUSSION. 



CHAPTER I, 

INTRODUCTION. 

Definition of percussion and auscultation — The sounds obtained by 
these methods of representing healthy and morbid physical condi- 
tions—Definition of signs— The basis of our knowledge of signs the 
constancy of association of certain sounds with certain physical con- 
ditions in health and disease — The present state of perfection of 
our knowledge of signs furnished by auscultation and percussion — 
Requirements for the successful study of these methods of explora- 
tion — The anatomy and physiology of the chest — An enumeration of 
the points relating thereto which are of special importance — The 
physical conditions incident to the different diseases of the chest: the 
conditions relating to the respiratory system stated, and a summary 
of them — The distinctive characters of healthy and morbid signs ; 
variations in intensity, pitch, and quality, considered as the chief 
source of the characters distinguishing the signs of disease from each 
other and from those of health — Other distinctions than those of 
intensity, pitch, and quality — The analytical method of the study of 
auscultation and percussion — The significance of signs as regards the 
physical conditions which they severally represent — Morbid condi- 
tions, not individual diseases, represented by the morbid signs — 
Regional divisions of the chest — Anatomical relations of the regions 
severally to the parts within the chest. 

Physical Exploration. 

The physical exploration of the chest embraces six 
different methods, namely: Auscultation, percussion, 



14 INTRODUCTION. 

inspection, palpation, mensuration, and snccussion. Of 
these, auscultation and percussion, dealing with sounds, 
involve the sense of hearing. In percussion, the sounds 
are produced by striking upon the walls of the chest; 
in auscultation, they are caused by acts of breathing, 
speaking, and coughing. 

The sounds in auscultation and percussion are: 1st, 
normal or healthy sounds, being produced when there is 
no disease of the chest; and, 2d, abnormal or morbid 
sounds, being produced when the chest is the seat of 
disease. The sounds, healthy and morbid, constitute 
what are known as physical signs. Frequently, for the 
sake of brevity, the term signs, without the word 
physical, is used to denote these sounds. Convention- 
ally, physical signs, or signs, are terms employed in a 
sense of contradistinction to the term symptoms. The 
signs are distinguished, of course, as normal or healthy, 
and abnormal or morbid. 

The sounds which constitute signs represent certain 
physical conditions pertaining to the chest. The normal 
or healthy signs represent physical • conditions existing 
when the organs are not affected by disease ; the abnormal 
or morbid signs represent physical conditions which are 
deviations from those of health, being incident to the 
various diseases of the chest. The physical conditions 
represented by signs may be distinguished as normal or 
healthy, and abnormal or morbid conditions. 

The representation of healthy and morbid physical 
conditions by certain healthy and morbid signs is estab- 
lished by having ascertained a constancy of association 
of the signs with the conditions. This constancy of 
association is ascertained by observation or experience. 
The sounds obtained by percussion and auscultation in 



PHYSICAL EXPLORATION". 15 

health are thereby established signs of healthy condi- 
tions, and the sounds obtained only in cases of disease 
are thereby established signs of morbid conditions. Our 
knowledge of certain sounds as the signs of certain 
physical conditions can have no reliable basis other than 
the constancy of the connection of the former with the 
latter. This constancy of connection is determined by 
the study of the sounds during life and examination o± 
the organs after death. The existence of certain condi- 
tions is not to be inferred from the characters of certain 
sounds until the connection of the sounds with the 
conditions has been ascertained by experience ; then, and 
then only, are the sounds to be reckoned as signs of 
these conditions. So, also, it is not to be inferred from 
certain physical conditions found after death, that certain 
sounds must have been produced during life, until the 
connection between the conditions and the sounds has 
been ascertained by experience. In other words, our 
knowledge of signs as representing physical conditions, 
can rest on no other than a purely empirical foundation. 
Our knowledge of the signs representing the physical 
conditions in health and disease, thanks to the labors o± 
Laenncc, and of those who have followed in his foot- 
steps, has been brought to great perfection. The prac- 
tical object of this knowledge is to determine by means 
of auscultation and percussion, together with the other 
methods of exploration, the existence of either healthy 
or morbid physical conditions, and to discriminate the 
latter from each other ; that is to say, the practical 
object is diagnosis. The signs now known to represent 
physical conditions, healthy and morbid, taken in con- 
nection with symptoms and pathological laws, render, 
for the most part, the diagnosis of diseases of the chest 



1G INTRODUCTION. 

easy and positive. Hence, it becomes the duty of the 
medical student and practitioner to give to auscultation 
and percussion attention sufficient, at least, for their 
practical application to the diagnosis of the diseases 
commonly met with in medical practice ; and this duty 
is the more imperative because it involves neither pecu- 
liar difficulties nor great labor. In entering upon the 
undertaking it is important to consider the requirements 
for the successful study of this province of practical 
medicine. These requirements relate to : 1st, the anat- 
omy and physiology of the chest; 2d, the morbid 
physical conditions incident to the different diseases of 
the chest ; 3d, the distinctive character of healthy and 
morbid signs ; and, 4th, the significance of the signs as 
regards the physical conditions which they severally 
represent. 

Anatomy and Physiology of the Respiratory Organs. 

The necessity of a knowledge of the anatomy and 
physiology of the chest, as a requirement for the study 
of auscultation and percussion, together with the other 
methods of physical exploration, is too obvious to need 
any discussion. The physical conditions of health must 
be known as preparatory for appreciating the physical 
conditions of disease. It would be absurd to think of 
studying the latter until the former are known. The 
student, therefore, who is not acquainted with the 
anatomy and physiology of the chest, must defer enter- 
ing upon the study of physical diagnosis until this 
requirement is fulfilled. Familiarity with the morbid 
physical conditions is necessary ; and for the advanced 
medical student or the practitioner it is advisable to 



ANATOMY AND PHYSIOLOGY OF CHEST. 17 

refresh the memory with a reviewal of certain anatom- 
ical points before beginning the study of auscultation 
and percussion. These points, relating especially to the 
physical conditions of health, cannot be considered in 
this work. A simple enumeration of them can only be 
introduced, the reader being referred for details to 
treatises on anatomy and physiology. 

Important anatomical conditions relate to the bones 
of the chest, namely, the general conformation of the 
thorax ; the differences in respect of the obliquity of the 
ribs from above downward ; the direction of the costal 
cartilages, their connection with the sternum, and the 
angles formed by the junction of the ribs and cartilages; 
the differences in width of the intercostal spaces in the 
upper, middle, and lower portions of the anterior, lateral, 
and posterior aspects of the thorax, together with the 
relations of the scapula and clavicle. The relative 
thickness of the muscular covering of the chest in dif- 
ferent situations is to be considered, and, in women, the 
varying size of the mammae. The attachments of the 
diaphragm to the thoracic walls, and its relations to the 
organs below, as well as above it, are points of impor- 
tance. Figs. 1, 2, 3, 4. 

Important physiological conditions relate to the parts 
which the ribs, costal cartilages, sternum, and diaphragm 
severally play in the movements of respiration. The 
differences, in respect of these movemeuts, in tranquil 
and in forced breathing ; the contrast between the two 
sexes, and between early and advanced life, are points 
to be studied. Other points are, the frequency of the 
respirations in health, and the relative duration, rapidity, 
and force of the inspiratory and the expiratory move- 
ments. • 



18 INTRODUCTION. 

Certain anatomical and physiological points pertain 
to the organs within the chest. The more important of 
these, relating to normal physical conditions, are the 
following : 1st, as regards the lungs, the connections of 
the pleura, and the smoothness of the pleural surfaces 
in contact with each other ; the relations of the apex 
and base of each lung to the chest-walls, and the differ- 
ences of the two lungs in this respect ; the relative 
spaces occupied respectively by the two lobes of the left, 
and the three lobes of the right lung ; the situation of 
the interlobar fissures in either side on the posterior, 
lateral, and anterior aspects of the chest; the arrange- 
ment of the air-vesicles, pulmonary lobules, and the 
different-sized intra-pulmonary bronchial tubes ; the ex- 
pansion of the air-vesicles, and the movement of the 
current of air from larger to smaller bronchial tubes in 
the act of inspiration, the vesicles diminishing in size, 
and the current of air moving from smaller to larger 
tubes in the act of expiration ; the difference in respect 
of the relative proportion of air and solids at the end of 
inspiration and at the end of expiration; the extent to 
which the volume of the lungs may be diminished by a 
forced act of expiration, and increased by a forced act 
of inspiration ; the relations of the apices to the sub- 
clavian arteries, and the variable extent to which the 
apex rises on either side above the clavicle. 2d, as 
regards the larynx, trachea, and the bronchial tubes 
outside of the lungs, the anatomy and physiology of the 
vocal chords, of the muscles concerned in the move- 
ments of respiration and of phonation, with the relations 
of each to the recurrent laryngeal nerve, the size of the 
rima glottidis in youth, after puberty, and relatively in 
the two sexes, the enlargement of the rima in the act of 



ANATOMY AND PHYSIOLOGY OF CHEST. 19 

inspiration, and diminution of its size in the act of expi- 
ration, and the closer approximation of the chords in 
the act of coughing ; the difference in the amount of 
areolar tissue above the vocal chords in children and in 
adults ; the situation of the trachea, and the point of 
its bifurcation ; the length, direction, and size of the two 
primary bronchi contrasted with each other, and the 
branches which penetrate the lungs. 3d, as regards the 
heart, the boundaries of the space which it occupies — 
that is, of the precordial space ; the relation of the 
aorta and pulmonic artery to the walls of the chest ; the 
portions of the precordial space in which the heart is 
covered and uncovered by lung; the situations of the 
auricles and ventricles respectively ; the relations of 
these to each other, and the arrangements of the valves ; 
the currents of blood through the orifices within the 
heart, and the relations of each of these to the heart- 
sounds ; the rhythmical succession of these sounds; the 
differences which distinguish each from the other in 
respect of loudness, duration, tone, quality, extent of 
diffusion, and the situation in which each has its maxi- 
mum of intensity; the mechanism of these sounds, and 
the situation of the apex-beat. Figs. 1, 2, 3, 4. 

The foregoing are the anatomical and physiological 
points which especially claim attention with reference to 
normal physical conditions, preparatory to entering on 
the study of abnormal physical conditions represented 
by the signs furnished by auscultation aud percussion 
together with the other methods of physical exploration. 

It is recommended to the student, before proceeding 
further, cither to acquire or review knowledge respecting 
all these points. Knowledge of these should be made 



20 INTRODUCTION. 

familiar, if it be not already so, by reference to works 
treating of the anatomy and physiology of the chest. 

Physical diagnosis is an art; like every art it has its 
limitations. Failure to realize this fact leads to error 
and disappointment. Morbid processes, which do not 
immediately cause coarse structural changes, or marked 
disturbances of function, may not appreciably modify 
normal physical signs ; again, lesions constituting im- 
portant changes in the physical structures of organs 
may be limited in extent and deeply situated, and thus 
elude the methods of physical exploration. 

The Morbid Physical Conditions Incident to the Different 
Diseases of the Respiratory System. 

The various morbid physical conditions incident to 
different diseases must be known, for it is the immediate 
object of auscultation, percussion, and the other methods 
of exploration, to ascertain either the existence or the 
absence of these morbid conditions. Knowledge of all 
the important conditions which are deviations from 
those of health, and the relations of each to different 
diseases, is, therefore, an essential requirement. 

Deviations from the normal conformation of the chest 
and the various abnormal movements of respiration, 
belong properly among the physical signs obtained by 
inspection, palpation, and mensuration. For the most 
part, these signs represent morbid physical conditions 
within the chest. Certain conditions relate to the pres- 
ence of liquid, either serous, sero-tibrinous, or purulent, 
within the pleural sac. The quantity of liquid may be 
large enough to compress the lung into a solid mass, 
and to enlarge the affected side, at the same time re- 



DISEASES OF RESPIRATORY SYSTEM. 21 

straining or annulling the respiratory movements ; the 
chest on the affected side, then, will contain only lung 
solidified by compression, and liquid. In other cases 
the quantity of liquid is either small, moderate, or con- 
siderable, the lung then containing a lessened quantity 
of air, and its volume diminished in proportion to the 
amount of liquid. These morbid conditions are incident 
to simple pleurisy with effusion, pyothorax or empyema, 
and hydrothorax. 

The pleural surfaces, in cases of pleurisy, may be 
more or less covered with recent fibrinous exudation, 
and, when not separated by the presence of liquid, they 
do not move upon each other smoothly and noiselessly. 
The friction of the opposed surfaces is still more pro- 
ductive of audible and sometimes tactile signs after the 
absorption of liquid, when the exudation has become 
more adherent and dense than when it is recent. 

The presence of air in the pleural space, either alone 
or with more or less liquid, in pneumothorax, may 
compress the lung into a solid mass, also dilating the 
affected side, and restraining or annulling its move- 
ments; and the air, with or without liquid, when not 
in sufficient quantity to produce these effects, may 
diminish more or less the volume of the lung and 
the amount of air in the pulmonary vesicles. These 
morbid conditions give rise to characteristic physical 
signs. The perforation of lung, usually existing in 
cases of pneumothorax, occasions additional signs which 
are characteristic. 

Solidification of lung is an important physical condi- 
tion incident to several diseases, irrespective of the 
condensation, just referred to, caused by the compression 
of liquid or air in the pleural sac. Complete consolida- 



22 INTRODUCTION. 

tion of an entire lobe, or of two and even three lobes, 
exists in the second stage of lobar pneumonia. Certain 
physical signs represent this condition of complete solidi- 
fication. The different degrees of solidification, namely, 
slight, moderate, and considerable, occur during the 
stage of resolution in cases of pneumonia, and these 
gradations are severally represented by well-defined 
characters pertaining to physical signs. Solidification, 
circumscribed, forming nodules which vary in size and 
number, situated in the upper, lower, or middle portion 
of the lung, either on one side or on both sides, exists 
in phthisis, in broncho-pneumonia and collapse of pul- 
monary lobules, in hydatids, in hemorrhagic iufarctus 
and embolic pneumonia, in pulmonary gangrene, and in 
carcinoma. It exists, greater or less in degree and more 
or less extended, in interstitial pneumonia. In these 
different connections the existence of solidification, its 
degree and extent, its limitation to one situation or its 
existence at different points, are determinable by means 
of physical signs. 

A morbid condition the opposite of solidification is an 
abnormal accumulation of air within the air-vesicles of 
the lungs. This is incident to pulmonary or vesicular 
emphysema, involving a morbid dilatation of the air- 
vesicles. The permanent expansion and increased vol- 
ume of the upper lobes in some cases of this disease, 
occasion a characteristic deformity of the chest, together 
with certain deviations from the normal movements of 
respiration, which are also characteristic. This morbid 
condition is represented by distinctive sigus furnished 
by auscultation and percussion. The extravasation of 
air in the connective tissue, constituting interlobular and 



DISEASES OF RESPIRATOEY SYSTEM. 23 

subpleural emphysema, in like manner gives rise to 
signs furnished by these methods of exploration. 

The presence of a viscid exudation within the air- 
vesicles and bronchioles, is a morbid physical condition 
incident to acute pneumonia, especially in its first stage, 
agglutinating the cells and bronchioles, the walls of 
which may be brought into contact or close proximity at 
the end of the act of expiration. The separation of the 
walls thus agglutinated, in the act of inspiration, gives 
rise to an auscultatory sign (the crepitant r&le) which is 
characteristic of that disease. 

An accumulation of serum within the air- vesicles con- 
stitutes the condition called pulmonary oedema. This 
condition gives rise to signs furnished by auscultation 
and percussion. 

Liquid within the bronchial tubes (serum, pus, blood, 
or thin mucus) is a condition incident to pulmonary 
oedema, abscess either of the lung or situated elsewhere 
and evacuating through the bronchial tubes, phthisis, 
bronchial or pulmonary hemorrhage, bronchorrhoea and 
bronchitis. The passage of air through the different 
varieties of liquid in the tubes causes bubbling sounds 
which are appreciable on auscultation. The apparent 
size of the bubbles (coarseness or fineness) corresponds 
to variations in the calibre of the tubes in which they 
are produced and the relative pitch of the bubbling 
sounds denotes the absence or presence of solidification 
of the pulmonary substance surrounding the tubes in 
which the bubbles are produced and, within limits, the 
degree and extent of such solidification. Bubbling 
sounds more intense and on a larger scale are caused 
by the presence of liquid within the trachea and larynx, 
known as the tracheal rales or the death-rattle. 



24 INTRODUCTION. 

Diminished calibre of the bronchial tubes within the 
lungs, either localized or diffused, is a condition due to 
the presence of tenacious mucus, and the swelling of the 
mucous membrane in cases of bronchitis. In cases of 
so-called capillary bronchitis the condition may involve 
an alarming degree of obstruction. The same morbid 
condition is incident to bronchial spasm in asthma, 
occasioning in this disease great suffering, but without 
immediate danger. The condition is represented by 
auscultatory signs which enable the auscultator to differ- 
entiate the obstruction due to capillary bronchitis from 
that due to bronchial spasm. Permanent obliteration 
of more or less of the bronchial tubes is an occasional 
morbid condition. 

Obstruction of a bronchial tube, either within or out- 
side of the lung, is a morbid condition involving the 
loss of respiratory sound within the area of the bron- 
chial branches and vesicles not receiving air in conse- 
quence of the obstruction. The obstruction may be 
temporary, being caused by a plug of mucus of sufficient 
size to prevent the passage of air; the morbid condition 
is then incident to bronchitis. One of the primary 
bronchi may be obstructed temporarily by a plug of 
mucus, and obstruction of the larynx in childhood thus 
produced may be sufficient to cause death by suffocation. 
The inhalation of foreign bodies is another cause of 
obstruction within the larynx, trachea, or bronchi. A 
primary bronchus or the trachea may be pressed upon 
by an aneurismal or other tumor, and, in this way, more 
or less obstruction to the passage of air is produced. 
However produced, the situation of the obstruction and 
its degree are, in general, determinable by means of 
auscultatory signs. 



DISEASES OF RESPIRATORY SYSTEM. 25 

Dilatation of bronchial tubes occasions two morbid 
physical conditions differing as regards their ausculta- 
tory signs, namely, 1st, an enlargement of greater or less 
extent, the tubes preserving their cylindrical form; and, 
2d, a sacculated enlargement. The former occurs gen- 
erally in connection with solidification around the tubes 
from hyperplasia of the connective tissue, and is thus 
incident to interstitial pneumonia. The latter may give 
rise to signs which represent pulmonary cavities. 

Sacculated dilatations of bronchial tubes, and the 
cavities incident to phthisis, pulmonary abscess, and 
circumscribed gangrene of lung, are represented by 
well-marked and highly distinctive signs furnished by 
auscultation and percussion. The signs denote either 
that cavities have flaccid walls which collapse in expira- 
tion and expand in inspiration, or that, owing to solidi- 
fication of lung, they remain open during both acts of 
respiration. 

More or less of the space within the chest which, 
normally, is occupied by lung, may be encroached upon 
by aneurisms or other intra-thoracic tumors. This is a 
physical condition giving rise to notable morbid signs 
furnished by auscultation and percussion. 

Finally, an extremely rare morbid physical condition 
is the presence of more or less of the hollow viscera of 
the abdomen within the chest, in consequence of either 
a congenital deficiency in the diaphragm, or a wound 
penetrating this muscle (diaphragmatic hernia). 

The foregoing morbid physical conditions relate to 
the respiratory organs. Those relating to the heart are 
deferred in order that they may precede more imme- 
diately an account of the signs of cardiac disease. As a 



26 INTRODUCTION. 

requirement for the study of morbid physical signs, the 
foregoing morbid physical conditions must be understood 
and memorized. To assist the student in the latter, a 
summary of these conditions is appended. 

Summary of Morbid Physical Conditions Incident to 
Diseases of the Respiratory Organs. 

1. An accumulation of serous, sero-fibrinous, or puru- 
lent liquid sufficient to fill the affected side of the chest, 
and sometimes causing more or less enlargement. 

2. An accumulation of liquid partially, filling the 
affected side of the chest, the quantity being either 
small, moderate, or considerable. 

3. Fibrinous exudation on the pleural surface. 

4. Air with liquid within the pleural cavity, and 
perforation of lung. 

5. Air without liquid in the pleural cavity. 

6. Solidification of lung, either complete or approxi- 
mating to completeness. 

7. Solidification of lung, slight or moderate in degree. 

8. Dilatation of the air-vesicles, involving within 
them an abnormal accumulation of air. 

0. Extravasation of air within the pulmonary connec- 
tive structure. 

10. Exudation within air-vesicles and bronchioles. 

11. Liquid within air- vesicles. 

12. Liquid (mucus, serum, pus, or blood) within 
bronchial tubes of large, medium, or small size. 

13. Liquid within bronchial tubes of minute size. 

14. Obstruction of the pulmonary bronchial tubes by 
mucus, swelling of the mucous membrane, and spasm of 
the bronchial muscular fibres. 



HEALTHY AND MOKBID SIGNS. 27 

15. Obstruction of larynx, trachea, or bronchi ex- 
terior to the lungs, by plugs of mucus or foreign bodies. 

16. Obstruction of the trachea or a primary bronchus 
by aneurismal or other tumors. 

17. Dilatation of bronchial tubes, cylindrical or sac- 
culated. 

18. Pulmonary cavities. 

19. Tumor within the chest. 

20. Diaphragmatic hernia. 

The Distinctive Characters of Healthy and Morbid Signs. 

For the practice of auscultation and percussion it is 
essential to be able to recognize the signs, severally, 
which represent the different physical conditions in 
health and disease. It is essential to distinguish the 
morbid from the healthy signs, and to discriminate from 
each other, severally, the signs of disease. The recogni- 
tion and discrimination of signs require a knowledge of 
the distinctive characters belonging to each of them. In 
entering upon the study of the signs, therefore, it is a 
necessary requirement to know whence their distinctive 
characters are derived. To this point of inquiry the 
attention of the student is now invited. 

The signs being sounds, they are to be recognized and 
discriminated in the way in which we practically recog- 
nize and discriminate other sounds. It is not necessary, 
in order to do this, to study the science of acoustics. In 
becoming familiar with other sounds, for example, musi- 
cal notes produced by different instruments, or the varie- 
ties of the human voice, we do not have recourse to that 
science. It suffices for all practical purposes to contrast 
the sounds obtained by auscultation and percussion with 



28 INTRODUCTION. 

reference to very simple and obvious differences ; and, 
yet, it is necessary to understand very clearly in what 
these differences consist, or, in other words, the sources 
of the distinctive characters of these sounds. The more 
important of the differences between the sounds obtained 
by auscultation and percussion relate to intensity, pitch, 
and quality. The distinctive characters of most of the 
signs are derived from three sources. In becoming 
practically acquainted with the signs, they are to be con- 
trasted as regards intensity, pitch, and quality, precisely 
as we would bring other sounds into contrast in these 
three aspects. The distinctive characters of the signs, 
severally, are especially derived from their differences 
in these respects. The distinctions expressed by the 
terms intensity, pitch, and quality, are, therefore, to be 
made clear. 

Differences in the intensity of sounds are easily under- 
stood. One sound is more intense than another sound 
when it is simply louder, and varying degrees of in- 
tensity are expressed by such terms as feeble or weak 
and loud, to which may be prefixed adjectives of quan- 
tity, such as very moderate, etc. This is all that need 
lie said with reference to the first of the three aspects 
under which sounds are contrasted. It will be seen 
hereafter that intensity is an essential element in the 
distinctive characters of certain of the signs. 

Differences in the pitch of sounds are easily under- 
stood by those who have given any attention to music. 
The differences are expressed by the terms high and 
low, to which may be prefixed words denoting a greater 
or less degree of highness or lowness. A nice apprecia- 
tion of variations in the pitch of musical notes, requires 
what is known as a " musical ear ;" but a very nice 



HEALTHY AND MORBID SIGNS. 29 

appreciation is riot essential in comparing, as regards 
pitch, the sounds studied in auscultation and percussion. 
For the most part, these sounds are not musical notes ; 
nevertheless, differences in pitch are readily perceived. 
A musical ear is undoubtedly an advantage in readily 
distinguishing differences in pitch ; but it is by no means 
a sine qua non. For those who have given no attention 
to music, some difficulty may be at first experienced in 
judging correctly of differences in this regard ; but the 
difficulty disappears after a little practice. Differences 
in pitch now enter pretty largely into the distinctive 
characters of physical signs ; but by Laennec, and those 
who immediately followed him, comparatively little 
attention was paid to the study of signs with reference 
to these differences. The writer was led to engage in 
this study more than a quarter of a century ago, and 
hereafter, in giving an account of the different signs, he 
will claim to have been the first to indicate clearly 
certain characters from this source. 1 

Differences relating to quality are apt, at first, to be 
confounded with those relating to pitch ; hence the 
distinction between pitch and quality must be clearly 
understood. We may say of the quality of a sound, 
that it embraces whatever is not embraced in the terms 
intensity and pitch. This is true as a general statement. 
The sense of the term quality, in distinction from in- 
tensity and pitch, may be most readily made clear by 
an illustration. Let it be supposed that we hear the 
notes of an instrument which is unseen — the performer, 
for example, being in another room. We recoguize at 

1 Vide Prize Essay on " Variations of Pitch in Percussion and Respi- 
ratory Sounds, and their Application to Physical Diagnosis." Transac 
tions of the American Medical Association, 1852. 



30 INTRODUCTION. 

once the instrument by the notes, provided it be one 
with which we are familiar, such as a violin, a flute, a 
clarionet, etc. We do not need to see the instrument ; 
we recognize it by the sounds. Now, how do we recog- 
nize it '? Certainly not by the intensity of the sounds ; 
it matters not whether these be loud or weak, so that 
we hear them. Certainly not by the pitch ; for if a 
piece of music be performed, we get both high and low 
notes. We recognize the instrument by the quality of 
the sounds. Each musical instrument, owing to its 
peculiarity of construction, yields sounds which are 
peculiar to it ; and after we have become familiar with 
the quality of sounds peculiar to an instrument, we im- 
mediately thereby recognize it. Precisely in the same 
way we may recognize certain sounds produced by aus- 
cultation and percussion in health and disease. The 
signs differ in quality according to the physical condi- 
tions which they severally represent ; and differences in 
quality will be found hereafter to constitute essential 
and obvious distinctions by which the signs of health 
and disease are recognized and discriminated. This is 
a source of some of the most distinctive of the characters 
of certain of the physical signs. 

Of the peculiar quality of any particular sound one 
can form no definite idea otherwise than by direct ob- 
servation. That is to say, no one could describe to 
another the peculiar quality of a particular sound so 
that it would be clearly apprehended without the sound 
having been heard. Imagine the attempt to describe 
the souud of a violin to a person who had never listened 
to the notes from that instrument — it would be impos- 
sible to give a correct idea of it in language. The only 
way in which an approximate idea could be conveyed 



HEALTHY AND MORBID SIGNS. 31 

in words, would be by comparing the quality to that of 
some other instrument to the notes of which there was 
some resemblance — that is, by analogy. To attempt to 
describe the quality of sounds to one who had never 
heard them, would be like describing colors to one 
blind. It will be seen hereafter that the quality of 
certain souuds obtained by auscultation and percussion 
is peculiar to them, and their distinctive characters in 
this respect can be known only by direct observation ; 
they cannot be learned by means of any verbal descrip- 
tion, nor by any comparisons — that is, by analogy. 

Appreciable variations in the quality of sounds are 
infinite. This may be illustrated by the human voice. 
Almost every person may be recognized from a peculiar 
quality of the voice by one who is familiar with it ; 
and the voices of thousands of persons, if compared, 
would present shades of difference — in fact, as is well 
known, it is extremely rare for the voices of any two 
persons to be so nearly identical in quality that they 
cannot be distinguished from each other. . As the diver- 
sity in quality of different sounds cannot be described, 
so they can only be designated by names which are 
significant from certain resemblances. Terms based on 
analogies which are used to' denote qualities of the 
sounds furnished by auscultation aud percussion are the 
following : rough, harsh, and rude, soft, blowing, hol- 
low, musical, moist, dry, bubbling, gurgling, crackling, 
clicking, rubbing, grating, creaking, tubular, cracked 
metal, sibilant or whistling, sonorous or snoring. All 
these names owe their significance to resemblances to 
other sounds. One sound furnished both by auscultation 
and percussion has a quality which is sui generis, and 
the term used to distinguish it is derived from its source, 



32 INTRODUCTION. 

namely, the vesicular resonance, and the vesicular mur- 
mur of the respiration. 

In addition to intensity, pitch, and quality, as sources 
of the distinctive characters of the signs furnished by 
auscultation and percussion, there are some other points 
of difference, namely, the duration of certain sounds, 
their continuousuess or otherwise, their apparent near- 
ness to, or distance from, the ear, their rhythmical suc- 
cession, and their strong resemblance to particular 
sounds, such as the bleating of the goat, the chirping of 
birds, etc. These points of difference are important, 
although less so than those relating to intensity, pitch, 
and quality. 

The study of the different sounds furnished by auscul- 
tation and percussion, with reference to distinctive char- 
acters relating especially to intensity, pitch, and quality, 
distinct signs being determined from points of difference 
as regards these characters, may be distinguished as the 
analytical method. It may be so distinguished in con- 
trast with the determination of signs deductively, taking 
as a standpoint either the physical conditions incident 
to diseases or the sounds. If we undertake to decide, 
a priori, that certain sounds must be furnished by 
auscultation and percussion when certain conditions are 
present, we shall be led into error; and so, equally, if 
we undertake to conclude from the nature of the sounds 
that they must represent certain conditions. The only 
reliable method is to analyze the sounds with reference 
to differences relating especially to intensity, pitch, and 
quality, and to determine different signs by these differ- 
ence?, the import of each of the signs being then estab- 
lished by the constancy of association with physical 



SIGNIFICANCE OF THE SIGNS. 33 

conditions. It is by this analytical method only that 
the distinctive characters of signs can be accurately and 
clearly ascertained. This is to be borne in mind by the 
student in physical exploration. He is to become 
acquainted with the different signs, and to recognize 
them in practice, by acquiring a knowledge of the dis- 
tinctive characters of each, as derived mainly from 
differences relating to intensity, pitch, and quality. 
The individuality of the signs, severally, can rest on no 
other solid basis. 

The Significance of the Signs as regards the Physical 
Conditions which they severally represent. 

Knowledge of the significance of the physical signs is 
the complemental requirement in the study of ausculta- 
tion and percussion. For the successful employment of 
these methods, in addition to the recognition of each 
sign by its distinctive characters, must be known its 
significance, that is, the physical condition which it 
represents. In this respect the signs may be compared 
to the substantives in language, each having a definite 
meaning. The signs furnished by these methods may 
be said to constitute a language with a very small 
vocabulary ; or, takiug as the standpoint the things 
signified, the different physical conditions are expressed 
by means of the signs. 

It is to be noted that the significance of the morbid 
signs relates immediately, not to diseases, but to the 
physical conditions incident thereto. Signs are not 
directly diagnostic of particular diseases. They repre- 
sent conditions not peculiar to one, but common to 
several, diseases. Thus, solidification of lung exists in 



34 INTRODUCTION. 

pneumonia, phthisis, pleurisy with effusion, collapse, and 
pulmonary cancer ; now, certain signs tell us that this 
morbid condition exists, together with its situation, its 
degree, and its extent. With this information the diag- 
nosis of the disease is made by connecting with it patho- 
logical laws, together with the history and symptoms. 
The student in physical exploration should by no means 
imagine that, for the diagnosis of disease, exclusive 
reliance is to be placed on the signs ; they are always to 
be taken in connection with pathological laws, the 
history, and the symptoms. Disconnected from these, 
the signs would often lead to error, and it is no dispar- 
agement to physical diagnosis that its reliability depends 
on other facts than those which belong exclusively to it. 
To repeat a statement already made more than once, 
the significance of the signs, as regards the conditions 
which they severally represent, is based on the constancy 
of their association with the latter, our knowledge of 
this association being derived from examinations during 
life and after death. 

Regional Divisions of the Chest. 

Before entering on the study of physical exploration, 
the student should become acquainted with the divisions 
of the surfaces of the anterior, posterior, and lateral 
aspects of the chest into circumscribed spaces which are 
called regions. These divisions, deriving their bound- 
aries and names from their anatomical relations, are 
sufficiently simple. 

Anteriorly the chest is divided into regions as follows : 
The supra- or post-clavicular region extends from the 
clavicle upward a short distance, corresponding to the 



REGIONAL DIVISIONS OF THE CHEST. 35 
Fig.1. 




The horizontal lines indicate the boundaries of the regional divisions 
on the anterior aspect of the chest. The vertical line is the linea mam- 
illaris. The oblique dotted lines indicate the interlobar fissures. 

ab,ac,cd, and bd, boundaries of superficial cardiac space, pouter 
boundary of deep cardiac space; ce, lower boundary of right lung; df, 
lower boundary of left lung ; gh, upper boundary of right and left lung ; 
Im, lower boundary of hepatic flatness ; pq, upper boundary of hepatic 
dulness; no, lower boundary of the stomach moderately distended. 



36 



INTRODUCTION. 



variable height to which the lung rises above this bone. 
The clavicular region embraces the space occupied by 



Fig. 2. 




The longitudinal and vertical lines indicate the regional divisions on 
the posterior aspect of the chest. 

ab, lower boundary of lungs; cd, lower limit of expansion of lungs: 
ef, interlobar fissures; h, spleen; /.lower boundary of liver: k. left 
kirlney; /, right kidney. 



REGIONAL DIVISIONS OF THE CHEST. 



37 



the clavicle. The infra-clavicular region embraces the 
space between the clavicle and the third rib. The 
mammary region is bounded above by the third and 




The horizontal line indicates the regional division of the lateral 
aspect of the chest. 

ab, lower boundary of right lung; cd, lower boundary of hepatic 
flatness ; cj\ upper boundary of hepatic dulness; g, border of kidney. 



38 



INTRODUCTION 



below by the sixth rib, and the infra-mammary region 
is the portion of the chest below the sixth rib. 

Posteriorly the divisions are into the scapular, the 
infra-scapular, and inter-scapular regions. The scapular 



Fig. 4. 




ab, boundary of hepatic flatness; <•-. lower boundary of left lung: 
(../'. </. h, i, k. 1. boundaries of spleen : Im, boundary of kidney : q, r, s, 
lower boundaries of the stomach in different degrees of distention. 



REGIONAL DIVISIONS OF THE CHEST. 6V 

region is the space occupied by the scapula, and is 
divided by the spinous ridge into the upper and lower 
scapular space. The infra-scapular region is the por- 
tion below a horizontal line intersecting the lower angle 
of the scapula. The inter-scapular region is the space 
between the posterior margin of the scapula and the 
spinal column. 

Owing to the great mobility of the scapula, the bound- 
aries of these regions are variable within considerable 
limits, according to the position of the arms. The fore- 
going description is based upon the position of the 
shoulder-blades when the patient is in the erect posture 
with the arms hanging at his sides. 

Laterally there are two regions, namely, the axillary 
and the infra-axillary. The axillary region is the space 
above a horizontal line extending from the lower border 
of the mammary region — i. e., the sixth rib. The infra- 
axillary region is the portion below the axillary region. 

The portion of the anterior surface occupied by the 
sternum is divided into the upper aud the lower sternal 
region, the space above the sternal notch being the supra- 
sternal region. 

In order to become familiar with the foregoing 
regional divisions, it is recommended to the student to 
delineate them with ink on the chest of the living sub- 
ject or a cadaver. Figs. 1, 2, 3, 4. 

It is advisable to study sections, extending from the 
surface to the centre of the chest, corresponding to the 
different regions, so as to become familiar with the rela- 
tion of each section to the parts contained within it. 
An enumeration of the more important of the anatomical 
relations of the different regions is as follows : 



40 INTRODUCTION. 

1. Supra-clavicular Region. — This is relative to the 
upper extremity or apex of the lung, which rises above 
the clavicle in different persons from half an inch to au 
inch and a half. The height is generally greater on one 
side, and this side is usually the left. 

2. Clavicular Region. — A small portion of the lung 
at or near the apex is contained in the section corre- 
sponding to this region. 

3. Infra-clavicular Region. — The parts situated here, 
exclusive of the upper sternal region (vide No. 7), are 
the upper portion of the lung, and the extra-pulmonary 
bronchi. The differences between the two primary 
bronchi, as regards direction, size, and length, are im- 
portant points in the study of this section. 

-t. Mammary Region. — The differences between the 
two sides in the section corresponding to this region are 
important. These differences relate especially to the 
praecordia, and are involved in the physical diagnosis of 
enlargement of the heart. The commencement of the 
interlobular fissures is in this region. On the left side 
the fissure is between the fourth and fifth ribs. On the 
right side the fissure between the upper and middle 
lobes begins at the fourth costal cartilage, and between 
the middle and lower lobes a short distance below. The 
situations of the fissures, however, differ considerably 
during the acts of inspiration and expiration. 

5. Infra-mammary Region. — This region differs in 
its anatomical relations considerably on the two sides of 
the chest. On the right side the liver pushes upward 
the diaphragm nearly or quite to the upper boundary, 
namely, the sixth rib. On the left side the section cor- 
responding to the region embraces, together with the 
anterior portion of the lower lobe of the lung, portions 



REGIONAL DIVISIONS OF THE CHEST, 



41 



of the stomach, spleen, and the left lobe of the liver. 
The variable volume of the stomach at different times 
occasions considerable variations in the relative spaces 
occupied by these different parts. 

6. Supra-sternal Region. — This region is in relation 
to the trachea. 

7. The Upper Sternal Region. — The bifurcation of 
the trachea is beneath the sternum at the centre of a line 
connecting the second ribs. Below this line the lungs 
on the two sides are nearly in contact at the mesial line, 
covering the primary bronchi. 

8. Lower Sternal Region. — The sternum in this re- 
gion covers the margin of the right lung, a large portion 
of the right and a little of the left ventricle. 

9. Scapular Region. — The sections corresponding to 
this region contain the posterior portion of the upper 
lobe and a portion of the upper part of the lower lobe 
of the lung. At the upper part of the lower scapular 
space terminates the fissure separating the upper and the 
lower lobe. The line of this fissure pursues an oblique 
course to the fourth or fifth rib on the anterior aspect 
of the chest. 

10. Infra -scapular Region. — On the right side the 
lung extends from the upper boundary of this region 
to the eleventh rib, the liver rising to the latter point. 
On the left side the section contains a portion of the 
spleen. 

11. Inter-scapular Region. — The trachea extends in 
this section to the fourth dorsal vertebra, where it bifur- 
cates. Below this point, on the two sides, are situated 
the primary bronchi. 

12. Axillary Region. — The section corresponding to 



42 INTRODUCTION. 

this region contains a portion of the upper lobe with 
large bronchial tubes. 

13. Infra-axillary Region. — This is in relation to the 
upper part of the liver on the right side, and on the left 
side to a portion of the spleen and stomach ; the re- 
mainder of the section is occupied by luug. 

It is recommended to the student to become familiar 
with the sections corresponding to the different regions, 
by dissections for this purpose, and the study of ana- 
tomical relations. Figs. 1, 2, 3, 4. 

Asking the student's careful attention to the intro- 
ductory considerations which have been presented, aus- 
cultation and percussion in health and disease, and the 
physical signs involved in the diagnosis of diseases of 
the respiratory system and of the heart, will be consid- 
ered as follows : Chapter II., Percussion in Health ; 
Chapter III., Percussion in Disease; Chapter IV., 
Auscultation in Health ; Chapter V., Auscultation in 
Disease ; Chapter VI., The Physical Diagnosis of Dis- 
eases of the Respiratory System ; Chapter VII., The 
Physical Conditions of the Heart in Health and Disease; 
Chapter VIII. , The Physical Diagnosis of Diseases of 
the Heart ; and, as properly embraced in the scope of 
this treatise, Chapter IX. will be devoted to the Diag- 
nosis of Thoracic Aneurisms. 



CHAPTER II. 

PERCUSSION IN HEALTH. 

Percussion with the fingers or with a pereussor and pleximeter — The 
normal vesicular resonance on percussion ; its distinctive characters 
relating to intensity, pitch, and quality — Variations in the characters 
of the normal vesicular resonance in different persons — Relation of the 
pitch of resonance to the vesicular quality — Tympanitic resonance over 
the abdomen — Variations of the normal resonance in the different re- 
gions of the chest — Enumeration of the regions in which the resonance 
on the two sides varies, and those in which it is identical in health — 
Influence of age on the normal resonance — Influence of the acts of 
respiration on the resonance. Rules in the practice of percussion. 

Percussion may be performed with either the fingers 
(finger percussion) or artificial instruments (pleximetry). 
The fingers suffice for the study and in ordinary prac- 
tice. Instruments are preferable only when it is desired 
to produce sounds to be heard at a distance, as in class 
illustrations, and when, from the number of patients to 
be percussed, as in dispensary or hospital practice, the 
frequent repetition of the blows renders the fingers tender 
and painful. The instruments are a pleximeter and a 
pereussor. A simple and convenient pleximeter is an 
oval disk of ivory or hard India-rubber, with projecting 
handles or auricles sufficiently large and roughened on 
their outer aspect so as to be conveniently held by the 
fingers. The author has lately used with satisfaction a 
pleximeter consisting of a piece of hard rubber bent up- 
ward at one extremity, and ending in a handle. (Fig. 
6.) The best pereussor is a double cone of caoutchouc 



14 



PERCUSSION IN HEALTH. 



encircled at its centre with a handle of convenient length 
and size, the ring and the handle made of vulcanized 
rubber. The instrument is very durable. (Fig. 7.) 




li.ihber Plexin 



When percussion is performed with the ringers, the 
palmar surface of one or more of those of the left hand 




should be applied to the chest, with pressure sufficient 
to condense the soft structures, and the blows are given 



Fig. 7. 




Flint's Peroussor. 



with one or more of the lingers of the right hand bent 
at the secoud phalangeal joint so as to form a right 
angle. In giving the blows, the movements should be 



NORMAL RESONANCE. 



45 



limited to the wrist-joint, the ends, not the pulp, of the 
percussing fingers being brought into contact with the 
dorsal surface of the finger or fingers applied to the 
chest. The percussing fingers should be withdrawn in- 
stantly the blow is given. The type of perfect percus- 
sion is the movement of the hammers when the keys of 
a pianoforte are struck. The force of the percussion 
should never be sufficient to give pain to the patient ; 
generally either light or moderately forcible blows suf- 
fice. The requisite tact in the performance of percussion 
is acquired by a little practice. 

The first object in the study of percussion is to become 
acquainted with the characters which are distinctive of 
the sound obtained thereby from the healthy chest. For 
this object the percussion may be made either in the 
infra-clavicular region of either side, or in the infra- 
scapular region, the sound in these situations being 
louder — more intense — than in other regions. Percus- 
sion being performed, a sound or resonance is produced. 
This sound or resonance is now to be analyzed with 
reference to characters derived from intensity, pitch, and 
quality. What are these characters? The intensity 
will depend, other things being equal, on the force of 
the blow ; the resonance is comparatively feeble with a 
slight, and loud with a strong, percussion. Other cir- 
cumstances affect the intensity, irrespective of the force 
of the blow, namely, the volume of the lung, the elas- 
ticity of the costal cartilages, and the thickness of the 
soft parts which cover the chest. Owing to these cir- 
cumstances, the intensity of the resonance is by no means 
similar, in the same situation, in all healthy persons; it 
is comparatively feeble in some and loud in others. 
There is nothing distinctive of this normal resonance to 
3* 



46 PERCUSSION IN HEALTH. 

be derived from intensity, and we say, therefore, that 
the intensity is variable. 

What is the pitch of this normal resonance ? The 
pitch of a sound is always relative; and, comparing this 
resonance with all the morbid signs obtained by percus- 
sion, it is lower in pitch. We say, therefore,' that the 
pitch of this normal resonance is low. The pitch, how- 
ever, is found to vary in different healthy persons. 

What is the quality of this normal resonance? It has 
a quality which is peculiar to it. In this respect it is 
not identical with any sound produced otherwise than 
by percussion over healthy lung either within or without 
the chest. The quality cannot, therefore, be learned by 
analogy, uor can it be described ; it can only be appre- 
ciated by direct observation. The peculiar quality is 
due to the fact that the resonance is from air contained 
in the pulmonary vesicles. This arrangement causes 
the peculiar quality, just as the construction of any par- 
ticular musical instrument causes the quality of tone 
peculiar to that instrument; hence, as it is convenient 
to give the quality a name, we call it the vesicular 
quality. This quality is not equally marked in all 
healthy persons, being as a rule more marked in pro- 
portion to the intensity of the resonance. 

This vesicular quality, as just noted, is peculiar to the 
pulmonary resonance. An approximative representa- 
tion of it is obtained by percussing either a sponge or a 
loaf of bread. The latter gives a closer imitation than 
the former. Each of these articles affords a resem- 
blance to the vesicular quality of resonance, for the 
reason that it contains air in an infinite number of small 
spaces, in this regard resembling the lungs. In order 
to represent this sign by percussing a loaf of breiid, the 



VARIATIONS IN NORMAL RESONANCE. 47 



loaf should be covered with a napkin, in order to lessen 
the noise produced by the contact of the finger or the 
percussor, and thus to elicit better resonance from the 
air contained in the interstices of the loaf. The upper 
crust stands in place of the thoracic wall. The reso- 
nance elicited illustrates the lowness of pitch with a 
pretty close approach to the peculiar quality of the 
normal vesicular resonance. 

The normal resonance, then, obtained by percussion, 
may be thus defined : 

A resonance of variable intensity, low in pitch and 
having a peculiar quality called vesicular. The word 
vesicular is frequently embraced in the name of this 
healthy sign ; it is also called the normal resonance, the 
normal pulmonary resonance, or the normal vesicular 
resonance. The last of these names is to be preferred. 

The normal vesicular resonance on percussion, as has 
been seen, is not uniform in all healthy persons ; not 
only is its intensity variable, but it varies in pitch and 
in the amount of vesicular quality. This may be easily 
illustrated by percussing successively in the same situa- 
tion, and with the same force, a series of persons who 
are assumed to be free from disease. Is there not in this 
fact an obstacle in practically determining this healthy 
.sign? The fact occasions no embarrassment for this 
reason : we determine, in each case, that the resonauce 
is normal by a comparison of the two sides of the chest, 
percussing in corresponding situations on the two sides 
and with the same force. There is no ideal standard 
of the normal vesicular resonance, but, by comparing 
the two sides of (he chest, the standard of health proper 
to each person is obtained. The laws of disease are such 
that, for all practical purposes, the standard of health is 



48 PERCUSSION IN HEALTH. 

in this way almost always available. Not withstanding 
the variations within the range of health, the lowness in 
pitch and the vesicular quality are sufficiently distinctive 
of this normal sign as compared with the morbid signs. 

The pitch of the vesicular resonance and its vesicular 
quality are in a uniform relation to each other; that is, 
the conditions giving rise to the peculiar quality also 
render the pitch low. In proportion as the vesicular 
quality is marked, the pitch is lowered, and, conversely, 
with diminution of the vesicular quality the pitch is 
relatively higher. This relation between the pitch and 
quality will be found to hold good in the resonance 
modified by disease as well as in health. Another rela- 
tion may be here stated, namely, whenever, in health or 
disease, a tympanitic quality is combined with the 
vesicular, and in proportion as the former predominates, 
the pitch of the resonance is raised. 

The pitch and quality of the normal vesicular reso- 
nance may be readily illustrated by percussing success- 
ively over the chest and the abdomen. The different 
sections of the alimentary canal generally containing 
more or less gas, a resonance is obtained by percussion 
over the abdomen. This resonance is, of course, devoid 
of the vesicular quality; in contradistinction to the 
latter, its quality is called tympanitic. This tympanitic 
resonance is not uniform in all parts of the abdomen, 
but everywhere the quality is tympanitic, that is, non- 
vesicular, and the pitch is everywhere higher than that 
of the normal vesicular resonance. The tympanitic 
resonance over the stomach is generally high in pitch, 
and frequently has a ringing or metallic intonation. 
The gastric tympanitic resonance recognized by these 
characters will be found to be involved frequently in 



RESONANCE IN DIFFERENT REGIONS. 49 

sounds produced by percussing over the chest. Gas in 
the caecum gives a still higher pitch of resonance. Over 
the colon the resonance is lower than over the csecum 
and stomach, and it is still lower over the small intes- 
tine. In all these situations, bringing the tympanitic 
in contrast with the normal vesicular resouauce, the 
peculiar quality of the latter and its lowness of pitch are 
rendered apparent. The term tympanitic resonance 
will be found to enter into the names of two of the 
morbid signs obtained by percussion. 

Having studied the characters of the normal vesicular 
resonance, and become practically familiar with them by 
percussing different healthy persons, the student should 
study the variations which this resonance presents in 
the different regions of the chest. In doing this he 
acquires more and more tact in the performance of per- 
cussion, and becomes more and more familiar with the 
characters in general of the normal vesicular resonance. 

Supra, or Post-clavicular Region. — The resonance 
here varies much in intensity in different persons. The 
vesicular quality is most marked in the central portions. 
Toward the sternal extremity the resonance acquires a 
tympanitic quality from the proximity to the trachea; 
it becomes vesiculotympanitic, a term which will be 
applied to one of the morbid signs. 

Clavicular Region. — Near the sternum the resonance 
is somewhat tympanitic from the proximity to the trachea. 
At the central portion the vesicular quality is more or 
less marked, and the intensity is diminished toward the 
acromial extremity. 

Infra-clavicular Region. — The resouauce in this region 
is more intense than elsewhere, except in the axillary 
and the infra-scapular regions. The vesicular quality is 



50 PERCUSSION IN HEALTH. 

combined with a tympanitic quality toward the sternum, 
the latter being derived from the primary and secondary 
bronchi. As always when the vesicular and the tym- 
panitic quality are combined, the pitch is raised. This 
combination in health and disease is recognized by the 
intensity, pitch, and quality. 

Scapular Region. — The resonance in this region is 
notably less intense than in the infra-clavicular region, 
owing to the presence of the scapula and its muscles. In 
proportion as the intensity is less, the vesicular quality 
is less marked. The resonance in health, however, is 
quite sufficient for morbid signs to be available in this 
situation. 

Inter-scapular Region. — The resonance in this region 
is weak in comparison with other regions, except the 
scapular, owing to the muscles which here cover the 
chest. In the upper part of the region the resonance is 
somewhat tympanitic from the relation to the trachea 
and bronchi. 

Mammary Region. — The right and the left mammary 
region are to be studied with reference to differences 
relating to the liver and the heart. On the right side, 
from the fourth rib downward, the resonance is dimin- 
ished, the convex extremity of the liver extending up to 
this height. At or a little below the lower border of 
this region on the mammary line, that is, a vertical line 
passing through the nipple, resouance ceases, the lower 
lobe of the right luug not extending below this point. 
Between the third and fifth ribs on this side near the 
sternum, the resonance is diminished, from the presence 
of a portion of the right auricle and ventricle. On the 
left side the resonance is diminished, within the precor- 
dial space. This space extends vertically from the third 



RESONANCE IN DIFFERENT REGIONS. 



51 



rib to the fifth intercostal space, and horizontally from 
the sternum to a point at or a little within the mammary 
line. The resonance is considerably diminished within 
what is called the superficial cardiac space. This space 
may be represented by a right-angled triaugle, the right 
angle formed by a vertical line drawn from a point on 
the median line intersected by a horizontal line connect- 
ing the fourth ribs, and a horizontal line intersecting 
the point of apex-beat in the fifth intercostal space ; an 
oblique line drawn from the centre of the sternum on a 
level with the fourth rib and the point of the apex-beat 
forms the hypothenuse of the right-angled triangle. 
This oblique line is, in fact, a curved, not a straight 
line (vide Fig. 1, p. 35), the convexity looking to the 
left side. Practically, however, it is near enough to 
accuracy to consider it the hypothenuse of a right-angled 
triangle. Within this space the heart is in contact with 
the thoracic wall. Outside of this space and within the 
prsecordia the heart is covered with lung, and the reso- 
nance on percussion is less diminished. It is a useful 
exercise for the student to observe the diminution of the 
area of the superficial cardiac space by a forced inspira- 
tion, as determined by percussion. Aside from the 
presence of the heart and the convex extremity of the 
liver, the resonance over the mammary is less than in 
the infra-clavicular region, being diminished by the pec- 
toral muscle, which varies considerably in bulk in dif- 
ferent persons, and in women by the mammary gland, 
the size of the latter varying very much in different 
women. The development of the mammae, however, is 
never so great as to preclude the useful employment of 
percussion in this region. 



52 PERCUSSION IN HEALTH. 

Infra-mammary Region. — In this region, as in the 
region above it, the two sides present notable differences 
owing to the situation of the organs below the diaphragm. 
On the right side, over the greater part, and sometimes 
the whole of this region, resonance is wanting, that is, 
percussion gives flatness. It is easy to delineate the 
boundary between the lower border of the right lung 
and the liver, or, as it is called, the line of hepatic flat- 
ness. It is also easy to distinguish above this line the 
height to which the upper extremity of the liver ex- 
tends, or, as it is called, the line of hepatic dulness. The 
situation of both these lines varies considerably in dif- 
ferent healthy persons. The distance between the two 
lines is from one to two inches. Both lines are affected 
considerably by a forced inspiration and a forced expira- 
tion. A forced inspiration depresses the line of flatness 
about one and a half inch. A forced expiration causes 
the line to rise from two and a half to five and a half 
indies. The distance, therefore, between this line at the 
end of a forced expiration, and at the end of a forced 
inspiration varies from four to seven inches. With ref- 
erence to the practice of percussion, as well as for the 
purpose of verification, these points should be studied. 
Not infrequently percussion over the right infra-mam- 
mary region yields a tympanitic resonance due to the 
distention with gas of the transverse colon. 

On the left side, the resonance in this region varies in 
different persons, in the same persons at different times, 
and in different portions of the region at the same time, 
the variations depending on the organs below the dia- 
phragm. Flatness is caused by the extension of the left 
lobe of the liver into this region about three inches to 
the left of the median line. The left portion of the 



RESONANCE IN DIFFERENT REGIONS. 



53 



region is iu relation to the spleen, an organ which varies 
considerably in size iu health as well as disease, its aver- 
age dimensions being about four inches in length and 
three inches in width. Between the spleeu and the liver 
lies the stomach, the volume of which is constantly fluc- 
tuating, owing to its varying solid, liquid, and gaseous 
contents. Distention of the stomach with gas occasions 
a tympanitic resonance which frequently is transmitted 
above into the mammary region in health as well as in 
disease. The space corresponding to the spleen is deter- 
mined by the vesicular resonance above and the tym- 
panitic resonance below, the latter boundary, however, 
not being very reliable on account of the ready conduc- 
tion of tympanitic resonance for a certain distance. 
The distention of the stomach with solid or liquid con- 
tents, of course, occasions flatness. The study of the 
infra-mammary regions with reference to the varia- 
tions in resonance arising from the relations to the organs 
below the diaphragm, is of much utility from the prac- 
tice, as well as the knowledge, which it involves. The 
exercise, of endeavoring to define the boundaries of these 
different organs in healthy persons, will be of great ser- 
vice to the student in acquiring tact in percussion, and 
in discriminating differences in the sounds obtained by 
this method. 

Sternal Regions. — In the upper sternal region, that 
is, above the lower margin of the second rib, the re- 
sonance is non-vesicular, being derived from air in the 
trachea above the point of bifurcation. Being non- 
vesicular, it is, of course, tympanitic, inasmuch as the 
resonance is always tympanitic in quality if wholly de- 
void of the vesicular quality. Between the second and 
third ribs, the inner borders of the two lungs approxi- 



54 PERCUSSION IN HEALTH. 

mating, the resonance has a vesicular quality more or 
less marked ; but owing to the remnant of the thymus 
gland, together with adipose substance, and the presence 
of the large vessels, the resonance is not intense in this 
situation. Below the third rib the resonance has modi- 
fications due to the combination of several different 
organs situated beneath the lower sternal region. On 
the right side of the mesial line is the inner border of the 
right lung, the greater part of the right and a portion of 
the left ventricle of the heart lying beneath; a portion of 
the liver extends into the lower part of this region, and a 
portion of the stomach when distended. The resonance 
thus varies in different situations, and often presents a 
mixed character. It is a useful exercise to endeavor to 
define by percussion the boundaries of the several 
organs which are here in juxtaposition. 

Infra-scapular Regions. — The resonance below the 
scapula is intense as compared with that over the 
scapula, and the vesicular quality is marked. The re- 
sonance extends to the eleventh rib, which is the lower 
boundary of the lung. On the right side, at or near 
this point, is the line of hepatic flatness, hepatic dulness 
extending from one to two inches above this line. The 
line of hepatic flatness and of hepatic dulness is lowered 
from one to two inches by a deep inspiration, and raised 
by a forced expiration. On the left side the resonance 
may receive a tympanic quality from the presence of gas 
in the stomach. 

Lateral Regions. — In these regions the resonance is 
relatively intense, and notably vesicular. On the right 
side the line of hepatic flatness is at the eighth rib, 
hepatic dulness extending above this line as in front 
and behind. On the left side the resonance may be 



EESONANCE IN DIFFERENT REGIONS. 55 

rendered somewhat dull by the presence of the spleen, 
but it often has a tympanitic quality from the presence 
of gas in the stomach. 

As has been stated, the normal vesicular resonance is 
not in all persons identical as regards intensity, pitch, 
and quality. There is, therefore, no fixed standard in 
these respects by which we can determine whether the 
resonance be normal or not. The standard proper to 
each person is to be ascertained by a comparison of the 
two sides of the chest ; each person, in other words, 
furnishes his own standard of health. But it is to be 
observed that all the regions do not normally correspond 
in respect of the resonance on the two sides. In the 
following regions the resonance is notably dissimilar on 
the two sides : The mammary, the infra-mammary, the 
infra-axillary, and the infra-scapular. There is less dis- 
parity in the resonance on the two sides in the following 
regions : The supra-clavicular, clavicular and infra- 
clavicular, the scapular and inter -scapular, and the 
axillary. In some of these regions, however, the reson- 
ance differs, and it is of practical importance to note the 
dissimilarity which thus belongs to health. This state- 
ment applies especially to the infra-clavicular region, a 
region which, as will be seen hereafter, is of great im- 
portance with reference to the signs of phthisis. In 
this region the resonance on the left side is somewhat 
more intense, more vesicular, and lower in pitch than is 
the resonance on the right side; per contra, the reson- 
ance is less intense, less vesicular, and higher on the 
right side. This account of these points of disparity 
between the two sides is based on an analogy of recorded 
observations in a series of healthy persons. 1 The stu- 

1 Vide Physical Exploration of the Chest, by the Author, L856. 



56 PERCUSSION IN HEALTH. 

dent should become practically familiar with the normal 
differences between the two sides, and in becoming so, 
the practical experience acquired in performing percus- 
sion will be of use. 

The normal resonance is affected by age. In early 
life, when the costal cartilages are flexible and elastic, 
the resonance is more intense and lower in pitch than in 
old age, when the cartilages are rigid and the vesicular 
structure of the lung more or less atrophied. 

The resonance varies considerably in the different 
regions at the end of a full inspiration and at the end 
of a forced expiration. With regard to this disparity, 
the following is an extract from a work on physical ex- 
ploration, published by the author in 1856 : 

"The percussion-sou ud may also be found to vary at 
different periods of an act of respiration in the same 
individual. The quantity of air contained within the 
air-cells, and consequently the relative proportion of air 
and solids, are by no means equal after a full inspiration 
and after a forced expiration. The difference in lung 
expansion may occasion an appreciable disparity in re- 
sonance, according as the percussion is made at the con- 
clusion of a full inspiration or a forced expiration. 
The disparity is not appreciable uniformly in different 
persons. This fact I have ascertained by noting the 
results of examinations made with reference to the point. 
When it does exist, it usually consists, contrary to what 
might perhaps have been anticipated, and the reverse of 
what is usually stated in works on physical exploration, 
in diminished resonance and elevation of pitch at the 
conclusion of inspiration. This is probably to be ex- 
plained by the greater degree of tension of the lungs 



RESONANCE IN DIFFERENT REGIONS. 57 



aud thoracic walls produced by inspiration voluntarily 
prolonged and maintained — a condition presenting phys- 
ical obstacles to sonorous vibrations more than sufficient 
to counterbalance the increased proportion of air within 
the cells. It is a curious fact, worthy of notice, that 
the two sides of the chest are not always found to be 
affected equally as regards the percussion-sound, at the 
conclusion of a full inspiration, contrasted with that 
after a forced expiration. I have observed the contrast 
to be more striking on the right than on the left side; 
and in one instance on the left side the resonance was 
less intense aud somewhat tympanitic after a full inspi- 
ration, while on the right side the opposite effect was 
produced, and the sound became quite dull after a forced 
expiration. In view of these variations in a certain 
proportion of instances incident to different periods of 
a single act of respiration, in some cases of disease in 
which it is desirable to observe great delicacy in the cor- 
respondence of the two sides, pains should be taken to 
percuss corresponding points at a similar stage of respi- 
ration, and the close of a full inspiration is, perhaps, 
the period to be preferred. Ordinarily, the liability to 
error from this source is obviated, either by repeating a 
series of strokes, first on one side and next on the other, 
or by percussing both sides repeatedly in quick succes- 
sion, in order mentally to obtain the average intensity 
and other characters of the sound during the successive 
stages of a respiration. The instances of disease, how- 
ever, are exceedingly rare, in which such nicety of dis- 
crimination is important.'" 

Prof. Da Costa has recently studied more fully the 
variations in this respect in the different regions in dis- 



58 PERCUSSION IN HEALTH. 

ease as well as in health, and he has distinguished this 
as "respiratory percussion." 1 

Kules in the Practice of Percussion. 

1. Prior to a comparison of the two sides of the chest, 
as regards the resonance on percussion, either in health 
or disease, an examination by inspection should be made, 
in order to determine whether there be any deviation 
from the normal conformation. In what has been stated 
concerning percussion in health, it is assumed that the 
chest is symmetrical. Want of symmetry may be due 
to congenital deformities, and to those caused by rachitis, 
chronic pleurisy, curvature of the spine, and injuries. 
Any deviation from the normal conformation will affect 
more or less the resonance in corresponding regions on 
the two sides. Due allowance is to be made for want of 
symmetry in determining morbid signs, and often the 
existence of these cannot be determined with positive- 
ness when there is considerable deformity. The signs 
obtained by auscultation are less affected by want of 
symmetry than those obtained by percussion. 

2. Attention to the position of the person examined 
is important with reference to the normal symmetry of 
the chest. If the person be standing or sitting, the 
position should be upright and the shoulders brought to 
a level. A little inclination of the body to one side, or 
a depression of one shoulder, will be found to affect 
perceptibly the normal resonance, when the two sides 
are compared. If the body be recumbent, it should be 
as nearly as possible on a level plane. These conditions 

1 Vide work on Diagnosis, fourth edition. L876. 






RULES IN PRACTICE OF PERCUSSION. 59 

are indispensable for a nice comparison of the two sides 
either in health or disease. 

3. In making a nice comparison, the person who per- 
cusses should be, as nearly as possible, either in front or 
behind the person percussed. Percussion made by one 
standing or sitting by the side of the person percussed 
is almost certain to produce disparity in resonance. 

4. Percussion made successively on one side and the 
other side must be in all respects the same in regard to 
the mode, the force of the blow, and the situation. A 
light percussion on one side, and a stroug percussion on 
the other side, will, of course, cause a disparity in the 
intensity of resonance. The percussion must be made 
in succession at points as nearly as possible equidistant 
from the median line, and from the summit or base of 
the chest. With reference to great nicety, the percus- 
sion, if made on the rib or intercostal space on one side, 
must be made on the rib or intercostal space on the 
other side. Great nicety of comparison also requires 
that if percussion be made on one side during the act 
of inspiration, it should be made on the other side during 
this act. The signs of disease, however, are generally 
so well marked that very close attention to these points 
is not necessary. 

5. A series of blows in rapid succession (5 or 7) is 
to be preferred to one or two, in practising percussion, 
difference in intensity, pitch, and quality being thereby 
better appreciated. 

(i. Percussion may be made lightly or forcibly, the 
Cornier being called superficial, and the latter deep per- 



60 PERCUSSION IN HEALTH. 

cussion. With light blows the resonance comes from 
the superficies of the lung and from within a limited 
area. With forcible blows the resonance is from a 
greater depth and a wider space. The result of these 
different modes of practising percussion may be illus- 
trated within the prsecordia in health. Comparing the 
resonance over the superficial cardiac space with that in 
a corresponding situation on the right side, duluess is 
more marked with light than with forcible blows, the 
resonance from the latter coming from a wider area. On 
the other hand, comparing the resonance over the deep 
cardiac space, dulness is more marked with forcible than 
with light blows, owing to the presence of lung between 
the heart and the walls of the chest. This rule is of 
importance in its application to percussion in disease. 

7. Percussion over the anterior portion of the chest, 
the person percussed leaning against a door, a broad 
partition, or a lathed wall, gives an increased intensity 
ot resonance. While it may be sometimes useful to 
resort to this procedure in the practice of percussion, it 
is, as a general rule, to be avoided. 



CHAPTER III. 

PERCUSSION IN DISEASE. 

Enumeration of the signs of disease furnished by percussion— Require- 
ments for a practical knowledge of these signs — The distinctive char- 
acters of the morbid physical conditions represented by, and the 
different diseases into the diagnosis of which enter, the signs, sever- 
ally, to wit, 1. Absence of resonance or flatness : 2. Diminished reso- 
nance; 3. Tympanitic resonance; 4. Vesiculotympanitic resonance : 
5. Amphoric resonance ; 6. Cracked-metal resonance — Sense of resist- 
ance felt in the practice of percussion, as a morbid sign. 

Percussion in cases of disease furnishes signs which 
represent morbid physical conditions incident to the 
different pulmonary affections • with these physical con- 
ditions and their relations to pulmonary affections the 
student is supposed to be familiar (vide page 20 et seq.). 

The signs of disease furnished by percussion are 
resolvable into six, namely : 1. Absence of resonance 
or flatness ; 2. Diminished resonance or dulness ; 3. 
Tympanitic resonance ; 4. Vesiculotympanitic reso- 
nance; 5. Amphoric resonance, and 6. Cracked-metal 
resonance. The two last named signs are properly 
varieties of tympanitic resonance, but it is most conve- 
nient to consider them as distinct signs. 

Knowledge of these six signs sufficient for their 
availability in physical diagnosis requires, first, a prac- 
tical acquaintance with the characters which distinguish 
each from the others, as well as from the normal reso- 
nance ; and second, a clear apprehension of the signifi- 
cance of each, that is, the morbid physical conditions 
4 



62 PERCUSSION IN DISEASE. 

which they severally represent. Under these two .as- 
pects the signs will now he considered. 

1. Absence of Resonance or Flatness. 

This sign is sufficiently denned by its name. It is 
absence of resonance or sound. Nothing is heard but a 
noise such as may be produced by percussing over a 
solid mass, for example, a limb composed of muscle and 
bone, or over a collection of liquid, for example, the 
abdomen in hydro-peritoneum or ascites. There being 
no resonance or sound, the sign has no characters per- 
taining to pitch or quality. It may be illustrated on 
the healthy chest by percussing in the right infra-mam- 
mary region below the line of hepatic flatness. 

There are four classes of morbid physical conditions 
giving rise to flatness on percussion, namely, 1st, the 
presence of liquid either in the pleural sac or in pulmo- 
nary cavities; 2d, liquid filling the air- vesicles ; -kl, 
complete solidification of lung ; and, 4th, a tumor 
within the chest. Flatness on percussion over the chest 
always represents one of these morbid physical condi- 
tions. 

These conditions are incidents to different diseases, 
as follows : 

1st. Liquid in the pleural cavity is incident to pleu- 
risy with effusion, empyema, and hydrothorax. A 
collection of pus constitutes pulmonary abscess, aud 
phthisical cavities, or those caused by circumscribed 
gangrene, may become filled with morbid liquid pro- 
ducts. 

2d. Serous effusion into the air-vesicles constitutes 
pulmonary (edema. Liquid blood extravasated charac- 



ABSENCE OF RESONANCE OR FLATNESS. 63 

terizes hemorrhagic iufarctus, pulmonary hemorrhage 
or pulmonary apoplexy. Pus infiltrating more or less 
of the parenchyma may be derived from an abscess 
either within the lung, or elsewhere, for example, the 
liver, and from the pleural cavity in empyema when 
perforation of lung takes place. 

3d. Solidification of lung occurs in pneumonia from 
an exudation within the air-cells ; it is produced by 
condensation from compression by liquid or air in the 
pleural sac, the pressure of a tumor, and by collapse ; 
it exists in cases of phthisis, in interstitial pneumonia, 
and in carcinomatous infiltration of lung. 

4th. Tumors within the chest are of different kinds, 
for examples, aneurisms and cancerous growths. In 
proportion to their size they occupy space belonging to 
the lung, as well as condensing the latter by pressure. 
Flatness may also be caused by the encroachment of 
organs situated below the diaphragm upon the thoracic 
space, as in cases of enlargement of the liver and 
spleen. 

Flatness on percussion in all these conditions is the 
same. The sign alone does not enable us to discrimi- 
nate the conditions from each other, nor to determine 
the existing disease. 

Finding this sign present, the particular condition 
and the disease in each case are to be determined by the 
situation of the flatness, its extent, the associated phy- 
sical signs furnished by auscultation, together with the 
other methods of exploration, and by the symptomatic 
phenomena. 



64 PERCUSSION IN DISEASE. 

2. Diminished Resonance or Dulness. 

The resonance on percussion is diminished, or there 
is dulness, when the solids or liquids within the chest 
are morbidly increased without increase in the quantity 
of air, the increased amount of solids or liquids not 
being sufficient to cause flatness. Diminution of air 
without increase of either solids or liquids, as in collapse 
of pulmonary lobules, also gives rise to dulness. We 
may formularize the physical conditions by saying that 
they consist in an abnormal proportion of solids or 
liquids over the air in the pulmonary vesicles. 

Dulness varies in degree. It may be slight, mode- 
rate, considerable, or great. These adjectives of quan- 
tity express sufficiently the variations in this regard. 
The degree of dulness corresponds to the amount of the 
relative disproportion of solids or liquids over the air 
within the chest. 

The pitch of sound is higher than that of the normal 
resouauce of the persons percussed. This is invariable; 
with dulness there is always more or less elevation of 
pitch. The quality is altered only in amount ; there is, 
of course, less vesicular quality in proportion as the 
intensity of the resonance is diminished. 

The characters which distinguish this sign, thus, are, 
lessened intensity of resonance, elevation of pitch, and 
weakened vesicular quality. 

The morbid conditions giving rise to this sign are 
those which, existing in a greater degree, give rise to 
flatness. Morbid products within the pleural sac, 
serum, pus, lymph, if not sufficient to cause flatness, 
give rise to dulness. The sign, therefore, occurs in 
pleurisy, empyema, and hydrothorax. The same is true 



DIMINISHED RESONANCE OR DULNESS. 65 

of pulmonary oedema, hemorrhagic infarctus, pulmo- 
nary hemorrhage, and purulent infiltration of lung. 
Solidification of lung, when not complete, occasions 
dulness; hence it is a sign in pneumonia, vesicular and 
interstitial, in phthisis, in condensation of lung from 
compression, in collapse of pulmonary lobules, and in 
carcinomatous infiltration. A tumor within the chest, 
not sufficiently large to cause flatness, gives rise to 
dulness. 

There are, however, some conditions giving rise to 
dulness, which are never sufficient to cause flatness. 
Pulmonary congestion limited to a lobe may diminish 
the resonance appreciably. The dulness may exist in 
the first stage of pneumonia, before, solidification from 
pneumonic exudation has taken place. A layer of 
lymph upon the pleural surfaces causes dulness after 
the liquid effusion in pleurisy has been removed, and 
after the vesicular exudation in pneumonia is absorbed. 
Dulness may also be caused by a considerable accumu- 
lation of mucus or coagulated blood within the intra- 
pulmonary bronchial tubes. 

The particular morbid condition which gives rise to 
dulness cannot, be inferred from the characters of the 
sign : the sign only denotes that some one of the dif- 
ferent morbid conditions exists. The condition which 
exists in each case, and the disease, are to be determined 
by the situation, extent, and degree of dulness, taken 
in connection with the information derived from other 
methods of exploration than percussion, together with 
the history and symptoms. 



66 PERCUSSION IN DISEASE. 

3. Tympanitic Resonance. 

Resonance is tympanitic whenever it is entirely devoid 
of vesicular quality; in other words, any resonance 
which is non-vesicular is tympanitic. The leading dis- 
tinctive character of the preceding sign (dulness) relates 
to intensity, whereas, the leading distinctive character 
of this sign relates to quality. Tympanitic resonance 
derives no distinctive character from intensity; it may 
be either more or less intense than the resonance of 
health iu the person percussed. This point is "to be 
emphasized, inasmuch as with many the idea of tym- 
panitic resonance involves increased intensity of sound ; 
a resonance, be it never so feeble, if it be non- vesicular, 
is tympanitic. If, however, the resonauce be quite 
feeble, it is not always easy to determine whether there 
be, or be not, any appreciable vesicular quality. As 
regards pitch, a tympanitic resonance is higher than the 
normal vesicular resonance. If there be any exceptions 
to this rule, they are extremely infrequent. The tym- 
panitic resonance over different parts of the abdomen 
is always higher in pitch than the resonance over healthy 
lung. 

The following are the morbid physical conditions 
which give rise to tympanitic resonance : 

1st. Air in the pleural cavity. It is, therefore, a 
sign of pneumothorax. Frequently in this affection 
the tympanitic resonance is more intense than the re- 
sonauce of health, the pitch being always more or less 
raised . 

2d. Pulmonary cavities containing air. It occurs, 
therefore, in cases of phthisis. In this disease the tym- 
panitic resonance is limited to a circumscribed space cor- 



TYMPANITIC RESONANCE. 67 

responding to the site and size of the cavity; whereas, in 
pneumothorax, it frequently exists over a considerable 
part or the whole of the affected side of the chest. 

3d. Complete solidification of the whole or a part of 
the upper lobe of lung. The tympanitic resonance 
under these circumstances must be derived from the air 
in the lower part of the trachea and the bronchial tubes 
exterior to the lungs. This is the explanation of the 
sign in the second stage of pneumonia affecting an upper 
lobe, and in certain cases of phthisis prior to the stage 
of excavation. Dilatation of the iutra-pulmonary bron- 
chial tubes, with solidification surrounding them, as in 
some cases of interstitial pneumonia or cirrhosis of lung, 
may give rise to tympanitic resonance. 

4th. Conduction of resonance from the stomach or 
colon containing air or gas. A gastric tympanitic reso- 
nance is frequently conducted over a part, and sometimes 
over the whole, of the left side of the chest. This is 
more likely to occur when the left lung is solidified. 
On the right side less frequently a tympanitic resonance 
may be conducted upward from the colon to a greater 
or less extent. 

Tympanitic resonance may be illustrated by percus- 
sion over the hollow abdominal viscera of the abdomen, 
provided they contain air or gas. The sign may be 
imitated by percussing an inflated bladder or India- 
rubber balls. The pitch will be found to vary accord- 
ing to the size and the degree of inflation of the bladder 
or balls. To illustrate this resonance in proximity to a 
vesicular resonance produced artificially, one-half of the 
soft portion of an oblong loaf of bread may be removed, 
leaving intact the upper crust. Percussion over this 



68 PERCUSSION IN DISEASE. 

half of the loaf illustrates the tympanitic, and over the 
other half the vesicular, resonance. 



4. Vesiculo-tympanitic Resonance. 

This name was proposed by the author many years 
ago to denote a sign with the following distinctive char- 
acters : The resonance increased in intensity; the quality 
a combination of the vesicular with a tympanitic, and 
the pitch high in proportion as the tympanitic quality 
predominates over the vesicular. 

The sign represents especially one morbid physical 
condition, namely, an abnormal accumulation of air in 
consequence of dilatation of the air-vesicles — that is, 
pulmonary or vesicular emphysema. The sign is also 
present in interstitial or interlobular emphysema. The 
relation of the sign to these affections renders it of great 
value in physical diagnosis. 

A. vesiculo-tympanitic resonance is obtained when the 
pleural sac is partially tilled with liquid, by percussing 
over the lung on the affected side. Although the pres- 
sure of the liquid diminishes the volume of the lung, as 
a rule it yields this sign. The resonance is vesiculo- 
tympanitic above the liquid when the latter is sufficient 
to fill a third, a half, or even two-thirds of the intra- 
thoracic space. The sign is also obtained over the upper 
lobe when the lower lobe is solidified in the second stage 
of pneumonia, and over the lower lobe when the upper 
lobe is solidified. 

A loaf of bread may be used to illustrate a vesiculo- 
tympanitic resonance, as follows : By means of a hollow 
cylinder remove longitudinal sections in one-half of the 
loaf, leaving the crust intact. The spaces thus produced 



AMPHORIC RESONANCE. 69 

yield a tympanitic resonance, and the portions which 
surround these spaces give the vesicular resonance. The 
vesicular and the tympanitic quality are thus combined, 
with elevation of pitch and increased intensity ; over 
the other half of the loaf the resonance is purely vesicu- 
lar. Another method of illustrating this sign out of 
the body is to inflate the human lungs, or the lungs of 
the sheep or calf, considerably beyond the limit of a 
normal inspiration. Inflated beyond that limit the 
emphysematous condition is produced, and the reso- 
nance represents that condition. 

5. Amphoric Resonance. 

Resonance is said to be amphoric when it has a 
musical intonation analogous to that produced by blow- 
ing over the mouth of an empty bottle. An amphoric 
sound is easily illustrated by filliping the cheek made 
tense, the mouth not completely closed, and the jaws 
separated, as is done when the sound of a liquid flowing 
from a bottle is imitated. By varying the size of the 
cavity of the mouth, the amphoric sound thus produced 
may be made to vary much in pitch. This illustration 
exemplifies the mechanism of the sign in disease. 

The sign represents a pulmonary cavity which is gen- 
erally phthisical. The conditions, aside from the exist- 
ence of the cavity, are, rigidity of its walls, so that 
they do not collapse, the presence, of course, of air within 
the cavity, and free communications with the bronchial 
tubes. These accessory conditions arc not constant, so 
that an amphoric resonance over a cavity is sometimes 
found, :iik1 at other times wanting. Directly after 
4* 



70 PERCUSSION IN DISEASE. 

having been wanting, it may be reproduced if the patient 
expectorate freely. 

When percussion is made with reference to this sign, 
the mouth of the patient should be open, and one or two 
rather forcible blows are better than a series of four or 
six. The amphoric sound may be often distinctly per- 
ceived if the ear be brought into close proximity to the 
patient's open mouth, when the sign is not appreciable 
otherwise. It may be rendered still more distinct by 
means of the binaural stethoscope, the pectoral extremity 
being close to the mouth of the patient. 

As a cavernous sign the amphoric resonance is very 
reliable ; but it docs not invariably denote a pulmonary 
cavity. It is obtained in some cases of pneumothorax, 
the pleural space filled with air forming a cavity which 
communicates with the bronchial tubes through a perfo- 
ration of the lung situated above the level of the liquid. 
It is sometimes obtained over a solidified portion of lung 
situated in close proximity to a primary bronchus, the 
resonance being derived from the air within the latter. 
It is occasionally produced by percussing over the site 
of the primary bronchus in the second stage of pneu- 
monia affecting an upper lobe. In children, owing to 
the yielding of the costal cartilages, it may even be pro- 
duced in health over a primary bronchus. In all these 
exceptional instances the associated signs and symptoms 
will prevent the error of attributing the sign to a pul- 
monary cavity. 

This sign is properly a variety of tympanitic resonance. 

6. Cracked-metal Resonance. 

The name of this sign, expressing an analogy to the 
sound produced by striking a cracked metallic vessel, 






CRACKED-METAL RESONANCE. 71 

denotes its peculiar character. It may be imitated by 
folding the hands so as to form a cavity and striking 
them upon the knee, in the familiar trick of producing 
in this way a sound as if metal coins were between the 
palms. This illustration also exemplifies the mechanism 
of the sign also for this reason called the money -jingle 
or cracked-pot sound. Like the sign last described, it 
is a variety of tympanitic resonance. 

The cracked-metal, like the amphoric, resonance repre- 
sents generally a phthisical cavity. Percussion is to be 
made in the same way as for the production of the am- 
phoric resonance, and, like the latter, the cracked-metal 
character is often perceived if the ear be brought close 
to the patient's mouth when otherwise it is not appreci- 
able. 

The cracked-metal and the amphoric resonance are 
often associated ; and the statements made with respect 
to the exceptional instances in which the latter is pro- 
duced, without the existence of a pulmonary cavity, will 
apply equally to the former. 

In addition to the acoustic phenomena produced by 
percussion with the fingers applied to the chest instead 
of a pleximeter, an abnormal sense of resistance is felt 
in certain conditions of disease. In health, with a 
somewhat forcible percussion, the walls of the chest are 
felt to yield in proportion as the costal cartilages are 
flexible. This yielding is diminished or ceases when a 
collection of liquid in the pleural cavity, or liquid in 
the air- vesicles, and solidification of lung, offer a me- 
chanical obstacle thereto. An abnormal sense of resist- 
ance on percussion, thus determinable by comparison of 
the two sides of the chest, is a sign representing some 



72 PERCUSSION IN DISEASE. 

one of the morbid physical conditions just named. 
This properly belongs among the signs obtained by 
palpation. The sign is to be taken in connection with 
other signs in determining the condition which exists in 
particular cases. 



CHAPTER IV. 

AUSCULTATION IN HEALTH. 

Importance of the study of the auscultatory sounds in health — Imme- 
diate and mediate auscultation— Advantages of the binaural stetho- 
scope — Rules to be observed in auscultation — Divisions of the study of 
auscultation in health — The normal laryngeal and tracheal respira- 
tion — The normal vesicular murmur ; its distinctive characters, and 
the variations in the different regions on the same side, and in cor- 
responding regions on the two sides of the chest— The normal vocal 
resonance — The laryngeal and tracheal voice and whisper — The nor- 
mal thoracic vocal resonance and fremitus ; the distinctive characters 
of each : the variations in different regions on the same side, and in 
corresponding regions on the two sides of the chest— The normal 
bronchial whisper, with its variations in different regions on the same 
side, and in corresponding regions on the two sides of the chest. 

The term auscultation, limited iu its applicatiou to 
the respiratory system, denotes the act of listening to 
the normal and abnormal sounds produced by respira- 
tion, voice, and cough. In this and the next chapter, 
the method of exploration thus named will be con- 
sidered in its application to the respiratory system ; it 
will be considered subsequently as applied to sounds 
relating to the circulatory system. 

The study of auscultatory sounds in health is essen- 
tial as preparatory for the study of auscultation in dis- 
ease. The student must be familiar with the normal 
sounds before undertaking to become acquainted with 
those which represent morbid conditions. Ample time 
and attention should be given to the study of ausculta- 
tion in health. The omission to do this is a frequent 



74 AUSCULTATION IN HEALTH. 

cause of difficulty aud want of success iu attaining to 
a satisfactory proficiency in physical diagnosis. The 
practical skill required in diaguosis may be obtained in 
advance by devoting sufficient study to the healthy 
chest before entering on the study of the auscultatory 
signs of disease. Moreover, as will be seen, some of 
the most important of the morbid signs have their ana- 
logues in certain normal sounds pertaining to the re- 
spiratory system. 

Auscultation is either immediate or mediate. It is 
immediate when the ear is applied directly to the chest, 
which may be either denuded or covered with a cloth or 
a single thickness of clothing. It is mediate when the 
sounds arc conducted to the ear by means of an instru- 
ment called a stethoscope. The student should practise 
both immediate and mediate auscultation. The direct 
application of the ear to the chest suffices for diagnosis 
in many cases of disease ; but there are sometimes 
objections to this by the patient on tiie score of delicacy, 
and by the auscultator on the score of the uucleanliness 
of the person examined. There are certain parts of 
the chest which can only be explored by the stetho- 
scope, and this instrument has the advantage of cir- 
cumscribing the space whence the auscultatory sounds 
are derived. Moreover, by means of the stethoscope, 
which is to be preferred over the great variety of in- 
struments heretofore in use, the sounds are heard much 
better than by immediate auscultation. 

The stethoscope which is to be preferred conducts the 
sounds into both ears, that is, it is binaural. In this 
consists its great superiority. At the present time what 
is known as Cammaun's stethoscope 1 seems to combine 

1 Invented by the late Dr. Cammann, of New York. 



AUSCULTATION IN HEALTH. 



75 



more recommendations than any other form of a binau- 
ral instrument. (Fig. 8.) The conduction into both 
ears renders the sounds much louder and more distinct 
than when they are heard with one ear in either mediate 
or immediate auscultation. Another advantage is, the 
mind is not distracted by sounds entering the ear not 
employed in auscultation. The advantages, however, 
of Cammann's stethoscope are not appreciated until 




Cammann's Stethoscope. 



after some practice. At first, a humming sound is 
heard which divides the attention and thus obscures the 
intra-thoracic sounds. After a little practice this hum- 
ming sound is not heeded, and it ceases to be any obsta- 
cle. Many who use the instrument only a few times 
are dissatisfied with it and discontinue its use, when, if 
they had used it longer, they would not have been will- 
ing to dispense with it. The author's experience with 
a large number of classes in private instruction has been 
this : at first, most members of a class prefer the ear 
applied directly to the chest; but, before the course of 
instruction is ended, the binaural stethoscope is so much 
preferred that it is difficult to enforce a fail- proportion 
of practice in immediate auscultation. 

Another reason for the fact that this stethoscope is 



76 



AUSCULTATION IN HEALTH. 



not sufficiently appreciated iu this country is that many 
of the instruments sold are defectively made. Unless 
proper attention has been paid to all the nice points of 
the stethoscope as devised by Cammann, an instrument 
is worthless. An instrument must be very good, or it 
is without value. The knobs which are to enter the 
ears must be of the right size ; if they enter too far they 
occasion pain. The curves at the aural extremity must 
be such that the aperture is in the direction of the mea- 
tus of the ear. The flexible tubes must not be stiff, 
and their movements must be noiseless. All the tubes 
must be unobstructed, for it is the air within the tubes 
which chiefly conducts the sounds. In the use of the 
instrument it should be applied to the chest without any 
intervening: clothing-. 1 

Many auscultators prefer the metal stethoscope with 
hard-rubber ear-piece, originally made by Hawkesley 
of London, and known by his name. It is convenient 
to carry, less cumbersome than the double stethoscopes 
in use, and an efficient instrument. 



Rules in the Practice of Auscultation. 

The rules to be observed in the practice of ausculta- 
tion, in health and disease, may be here introduced. 

1. In auscultation, as iu percussion, corresponding 
situations on the two sides of the chest are to be explored 
successively, and compared. When the stethoscope is 
used, the pectoral extremity must be applied on each 
side with the same degree of pressure ; this is especially 

1 The stethoscopes made by Tiemann & Co. and Ford & Co. are reli- 
able. 



RULES IN PRACTICE OF AUSCULTATION. 77 

essential in the comparison of vocal sounds. In imme- 
diate auscultation, the ear is to be applied with a certain 
degree of force, and a thin layer of clothing does not 
interfere materially with the perception of auscultatory 
sounds. The ear not applied to the chest may or may 
not be closed by the finger in listening to the respiratory 
sounds; it should be closed in listening to the vocal 
sounds, in order to prevent confusion from attention to 
the voice from the patient's mouth. 

2. In immediate auscultation, whenever practised, the 
auscultator should take a position which will not inter- 
fere with the sense of hearing, and not occasion a feeling 
of discomfort. These difficulties are in the way of 
auscultating with the body bent forward ; the sense of 
hearing is dulled by the detention of blood in the head, 
and the position cannot be maintained without discom- 
fort, The persou examined, if practicable, should be 
sitting, and the position for the auscultator is that of 
kneeling on one knee, and lowering, if necessary, the 
body, so that the head may be kept upright, These 
points are less important if the binaural stethoscope 
be used. 

3. When listening to respiratory sounds, it is gener- 
ally desirable that the person examined should breathe 
with somewhat greater force than in ordinary breathing; 
but it is important that the normal rhythm of respira- 
tion should be unchanged. Persons when requested to 
breathe with increased force are apt to err in breathing 
violently, and sometimes too slowly. The readiest mode 
of obtaining what is desired, is for the examiner to illus- 
trate it by his own breathing. A complete expiration is 
important in order to secure a satisfactory inspiration. 
It should, therefore, !><• made clear by explanation and 



78 AUSCULTATION IN HEALTH. 

illustration, that each expiration should be finished 
before the following inspiration. 

4. The ability to concentrate the mind upon the 
sounds to which the attention is directed, is essential 
to success in auscultation. All persons do not possess 
this ability in equal measure, and herein is an explana- 
tion in part of the fact that all are not alike successful. 
To develop and cultivate by practice the power of con- 
centration, is an object which the student should keep 
in view. Generally, at first, complete stillness in the 
room is indispensable for the study of auscultatory 
sounds ; with practice, however, this becomes less and 
less essential. 

The study of auscultation in health embraces the fol- 
lowing : 

1. The sounds produced by respiration as heard over 
the larynx and trachea, or the novum! laryngeal and 
tracheal respiration . 

2. The sounds heard over the chest in the acts of respi- 
ration. These sounds, coming chiefly from the air- 
vesicles, constitute what is called the normal vesicular 
murmur. 

3. The resonance heard over the chest in phouation, 
and the vibration or thrill produced by the loud voice, 
or the normal vocal resonance and fremitus. 

4. The sounds heard over the chest with the whispered 
voice, or, inasmuch as these sounds are conducted chiefly 
by the air in the bronchial tubes, the normal bronchial 
whisper. 

These four normal signs will be considered in the 
forgoing order. 



NORMAL RESPIRATION. 79 

Normal Laryngeal and Tracheal Respiration. 

For all practical purposes the laryngeal and the 
tracheal respiration may be considered to be identical, 
that is, the shades of difference between the sounds in 
these two situations are not of importance as regards 
the application to physical diagnosis. The laryngeal 
respiration is more readily studied than the tracheal, 
and for the study of both the stethoscope is necessary. 

Applying the stethoscope over the side of the larynx, 
the person examined breathing with some increase of 
force, but without any alteration in rhythm, a sound is 
heard with each of the two acts of respiration. The 
inspiratory and the expiratory sound, studied separately 
and contrasted with each other, have the following 
characters relating to intensity, pitch, quality, duration, 
and rhythm : The inspiratory sound is of variable in- 
tensity. In ordinary breathing it varies much in dif- 
ferent persons, and in different acts of breathing in the 
same person. It is always considerably intense in 
forced breathing. The pitch is high when compared 
with the inspiratory sound as heard over the chest. 
The quality of the sound is well defined by the word 
tubular ; the sound at once suggests a current of air 
through a tube. The duration of the sound is from the 
beginning to nearly, not quite, the end of the inspiratory 
act. The characters of the inspiratory sound, thus, are 
more or less intensity, a high pitch, a tubular quality, 
and a duration a little less than that of the act of in- 
spiration. 

An expiratory sound is always heard with forced 
breathing. As regards duration, it is as long as, or 
longer than, the sound of inspiration. Tn general it is 



80 AUSCULTATION IN HEALTH. 

more intense than the sound of inspiration. The pitch 
is higher than that of the inspiratory sound. The 
quality is the same as that of the inspiratory sound, 
namely, tubular. 

Repeating the characters distinctive of the normal 
laryngeal respiration, they are as follows : The inspira- 
tory sound is of variable intensity, high in pitch, and 
tubular in quality. The expiratory sound is as long as, 
or longer than, the inspiratory sound ; it is higher in 
pitch, and usually more intense. "Owing to the inspira- 
tory sound not continuing quite to the end of the in- 
spiratory act, there is a very short interval of silence 
between the two sounds. In this latter point consists 
the only variation between the rhythm of the acts of 
breathing and that of the sounds. 

The foregoing characters should not only be verified 
by the student, but he should become so familiar with 
them by practice that it requires no effort of the mind 
to recollect them. It will be seen hereafter that these 
characters of the normal laryngeal respiration are pre- 
cisely those which distinguish an important morbid 
physical sign, namely, the bronchial or tubular respira- 
tion. 

Normal Vesicular Murmur. 

This is the name usually given to the respiratory 
sounds heard over the different regions of the chest. 
These sounds should be studied with the ear applied 
directly to the chest (immediate auscultation), as well 
as with the stethoscope. In commencing the study, the 
middle of the anterior surface of the chest on the right 
side, to avoid the sounds of the heart, or still better, the 
posterior aspect below the scapula on either side, should 



NORMAL VESICULAR MURMUR. 81 

be selected. The person examined should breathe some- 
what more forcibly than in ordinary breathing, but not 
violently nor quickly, nor too slowly, the normal rhythm 
being unchanged. Children are better than adults for 
this study, owing to the greater intensity of the murmur 
in early life. 

The characters which belong to the inspiratory and 
the expiratory sound in the normal vesicular murmur 
are as follows : The inspiratory sound is of variable in- 
tensity. There is a wide variation in different healthy 
persons. In some persons it is so feeble as scarcely to 
be appreciable even with the binaural stethoscope. The 
pitch of the sound, compared with the inspiratory sound 
in the normal laryngeal or tracheal respiration, is notably 
low. The quality of the sound is peculiar; no distinct 
idea of the quality can be formed by any comparison. 
The name used to designate the quality is vesicular, 
this name only denoting that the air-vesicles are in some 
way concerned in the production of the sound. This 
vesicular quality must be impressed upon the percep- 
tion and memory by direct observation. The duration 
of the inspiratory sound is from the beginning to the 
end of the inspiratory act. 

An expiratory sound is not always, although gener- 
ally, appreciable. It is much less intense than the 
sound of inspiration. It is notably lower in pitch than 
the sound of inspiration. The quality of the sound is 
neither vesicular nor tubular. It may be called simply 
a blowing sound, and may be imitated by blowing with 
the mouth partially opened. The duration is much 
shorter than that of the inspiratory sound. 

The characters, thus, which distinguish the normal 
vesicular murmur are, an inspiratory sound variable in 



82 AUSCULTATION IN HEALTH. 

intensity, low in pitch, and vesicular in quality; an ex- 
piratory sound less intense than the inspiratory, still 
lower in pitch, von-vesicular and non-tubular, or simply 
blowing; the inspiratory sound continuing from the 
beginning to the end of the inspiratory act, and the 
expiratory sound beginning with the expiratory act but 
ending before this act is completed, its duration, rela- 
tively to the inspiratory sound, being variable, but 
averaging about a fifth. The inspiratory sound con- 
tinuing to the end of inspiration, and the expiratory 
sound beginning with the act of expiration, it follows 
that there is no interval of silence between the two 
sounds. It is to be remarked that an interval is not 
infrequently produced by the person examined holding 
the breath after inspiration is completed. This variation 
in rhythm of the acts, of course, produces a correspond- 
ing variation in sounds of breathiug. 

The characters of the normal vesicular respiration 
may be studied by inflating the lungs removed from the 
human cadaver, or from the sheep or calf, and applying 
the binaural stethoscope directly upon the pulmonary 
surface. In this experiment the vesicular quality is 
strongly marked. In the same way the tracheal respi- 
ration may be studied and its characters contrasted with 
those of the vesicular respiration. It is recommended 
to the student to resort to this readily available method 
to study the normal respiratory signs. 

Having become familiar with the characters of the 
normal vesicular respiration as compared with those of 
the normal laryngeal or tracheal respiration, the student 
may then proceed to study the former in the different 
regions of the chest. The murmur will be found to 
present variations in the different regions on the same 






NORMAL VESICULAR MURMUR. 83 

side, aucl in the corresponding regions on the two sides 
of the chest. The variations, within the range of 
health, in the latter are especially important. The fol- 
lowing account of the murmur in the different regions 
embodies the results of the analysis of a series of re- 
corded examinations of healthy persons. 1 

Right and Left Infra-clavicular Region. — The mur- 
mur in this region, on either side, differs more or less 
from the murmur as heard in the anterior regions below, 
or in the infra-scapular region. The vesicular quality 
in the inspiration is less marked. The pitch is higher. 
The expiratory sound is longer, less feeble, and higher 
in pitch. The difference between the two sides in this 
region is especially important with reference to diag- 
nosis. The inteusity of the inspiratory sound is almost 
invariably greater on the left side. Its vesicular quality 
is more marked, and the pitch is lower. Per contra, the 
inspiratory sound on the right side, in this region, is less 
intense, less vesicular, aud higher in pitch than the in- 
spiratory sound on the left side. In forced breathing 
the intensity of the murmur is increased more on the 
left than on the right side. The expiratory sound is 
sometimes wanting on the left, when it is heard on the 
right side. On the right side, the expiratory sound is 
longer than on the left side. It may be prolonged on 
the right side to nearly or quite the length of the in- 
spiratory sound. Sometimes on the right side the pitch 
of the expiratory is higher than that of the inspiratory 
on the same side, and it may have a tubular quality. 
A rare peculiarity is a prolonged, high, tubular expira- 
tory sound on both sides, analogous to the laryngeal or 
tracheal expiration. When this is the case, the pitch of 






84 AUSCULTATION IN HEALTH. 

the expiratory sound is higher on the left than on the 
right side. 

These several modifications of the respiratory mur- 
mur in the infra-clavicular region are marked in propor- 
tion as the sounds are studied near the sternum, that is, 
over the site of the primary bronchi. The respiratory 
murmur in this situation has been called the normal 
bronchial respiration, from its resemblance to the mor- 
bid sigu so named. It may be more properly called a 
vesiculo-tubular, or the normal broncho-vesicular respi- 
ration, the characters being those of the morbid sign 
which, uuder the latter name, will be described in the 
next chapter. 

In the diagnosis of diseases, especially of phthisis, 
due allowance must be made for the points of disparity 
which exist normally between the two sides of the 
chest in the infra-clavicular region. Without a practi- 
cal knowledge of these poiuts of disparity, error in diag- 
nosis can hardly be avoided. 

Right and Left Scapular Region. — As compared with 
the infra-clavicular region, the respiratory murmur 
heard over the scapula on either side is feeble, and the 
vesicular quality is less marked. The inspiratory 
sound is generally weaker and the pitch higher on the 
right than on the left side. The expiratory sound is 
more constantly heard on the right than on the left 
side. It may be prolonged on the right side, and is 
sometimes higher in pitch than the inspiratory sound. 
Compared with the left side, the murmur on the right, 
in this region, thus may have vesiculo-tubular or 
broncho-vesicular characters more or less marked. 

Right and Left Inter-scapular Region* — In the upper 
and middle portions of this region, the normal charac- 



NORMAL VOCAL RESONANCE. 85 

ters are the same as in the sternoclavicular portion of 
the infra-clavicular region. The same points of dis- 
parity between the two sides are more or less marked 
here as they are anteriorly over the site of the primary 
bronchi. 

Right and Left Infra-scapular Region. — The inten- 
sity of the murmur is greater than over the scapular 
region. In most persons there is no notable disparity 
between the two sides ; when a disparity exists, the 
intensity is greater and the pitch lower on the left side. 
A prolonged, high-pitched, bronchial expiratory sound 
is sometimes transmitted below the scapula on the right 
side. 

Right and Left Mammary and Infra-mammary Re- 
gions. — The inspiratory sound in these regions is less 
intense than in the infra-clavicular region ; the vesicular 
quality is more marked, and the pitch is lower. An 
expiratory sound is often wanting. 

Right and Left Axillary and Infra- axillary Regions. 
— The inspiratory sound in these regions is as intense 
as in any portion of the chest. The intensity is less in 
the infra-axillary than in the axillary region, and the 
pitch is lower. In some persons the murmur on the 
two sides presents no disparity, but in other persons the 
vesicular quality is somewhat more marked and the 
pitch is lower on the left than on the right side. An 
expiratory sound is oftener heard than in the mammary 
and infra-mammary regions. 

Normal Vocal Resonance. 

Laryngeal and Tracheal Voice. — It will prepare the 
student for the appreciation of the distinctive characters 



86 AUSCULTATION IN HEALTH. 

of the morbid signs pertaining to the voice, to study the 
vocal signs over the larynx and trachea. Applying the 
stethoscope either over the broad surface of the thyroid 
cartilage, or just above the sternal notch, and requesting 
the person examined to count with a moderate intensity 
of voice, the auscultator perceives a strong resonance, 
with a sensation of concussion or shock, and a sense of 
vibration, thrill, or fremitus. The voice seems to be 
concentrated and near the ear. Sometimes the articu- 
lated words are transmitted so as to be heard more or 
less distinctly. The laryngeal or tracheal voice thus 
(laryngophony, tracheophony) embraces different ele- 
ments, namely, 1st, the vocal resonance ; 2d, the con- 
centration and nearness to the ear; 3d, the vibration, 
thrill, or fremitus ; and 4th, the transmission of the 
speech, the latter corresponding to pectoriloquy. These 
different elements will be found to enter into the dis- 
tinctive characters of morbid vocal signs. 

The sounds heard over the larynx and trachea when 
words are spoken in a whisper should be studied, inas- 
much as important morbid signs relate to the whispered 
voice. Whispered words occasion little or no shock or 
thrill, but an intense, high-pitched tubular sound, with 
a sensation as if a current of air were directed into the 
ear through the stethoscope. This sound corresponds to 
the sound of expiration in laryngeal or tracheal respira- 
tion ; the two sounds are, in fact, identical if, as is the 
case with some exception's, the person whisper with the 
expiratory breath. Articulated words are transmitted 
with more or less distinctness, thus corresponding with 
the morbid sign called whispering pectoriloquy. 

Normal Thoracic Vocal Resonance and Fremitus. — 
The vocal resonance over the chest is to be studied both 



NOKMAL VOCAL RESONANCE. 87 

by means of the stethoscope and by immediate ausculta- 
tion. When -the latter or the single stethoscope is em- 
ployed, the ear not applied to the chest should be closed 
in order to exclude the entrance of sound from the 
mouth of the person examined. When the stethoscope 
is employed, care must be taken, in making a compari- 
son between the two sides of the chest, or between dif- 
ferent regions on the same side, that the pectoral ex- 
tremity of the instrument be pressed with an equal 
amount of force against the chest. The intensity with 
which the vocal resonance is transmitted is much affected 
by the degree of pressure with the stethoscope. 

The situations in which the student should commence 
the study of the normal vocal resonance are those selected 
for beginning the study of the normal vesicular murmur, 
namely, the middle of the anterior aspect of the chest 
on the right side, and below the scapula behind. 

With the stethoscope or the ear directly applied in the 
situations just named, the person examined should be 
requested to count one, two, three, in a uniform tone, 
and with moderate force. The examiner should himself 
pronounce these numerals, in order to show the manner 
of counting. This is far better than asking a question 
and studying the resonance during the answer of the 
person examined. The objection to the latter mode is, 
the attention of the examiner is divided between the 
characters of the thoracic resonance and the idea con- 
veyed by the answer. The characters of the vocal 
resonance in these situations are as follows : 

The voice is heard with an intensity which varies 
very much in different persons; in some the resonance 
is feeble, mid il may be almost inappreciable, while in 
others i( is quite intense. The intensity depends greatly 



88 AUSCULTATION IN HEALTH. 

on the loudness and lowness in pitch of the voice of the 
person examined. The resonance is notably weaker in 
women than in men. It is rarely attended with a sense 
of concussion or shock. It is di if used ; that is, it does 
not seem to be concentrated like the tracheal or laryn- 
geal vocal resonance. It evidently comes from a certain 
distance; that is, the sound does not seem to be near 
the ear. Impression of the distance of the sound is 
highly distinctive of the normal resonance as compared 
with a morbid vocal sign (bronchophony). The reso- 
nance is accompanied by a sense of vibration, thrill, or 
fremitus, the intensity of which, like the resonance, 
varies much in different persons. This fremitus is pro- 
perly not an acoustic but a tactile sign. The normal 
vocal fremitus, together with its abnormal modifications, 
belong to the method of physical exploration called pal- 
pation. It is, however, appreciated by the ear as well 
as by the touch, and may be studied in the practice of 
auscultation. The student should practically distinguish 
from each other, and study separately, the vocal reso- 
nance and vocal fremitus. 

From the foregoing characters the normal vocal reso- 
nauce may be defined as, diffused, distant, variable in 
intensity, and accompanied with more or less vibration, 
thrill, or fremitus. 

Having become practically familiar with these char- 
acters of the normal vocal resonance in the situations in 
which they are first to be studied, the next object of 
study relates to the normal variations in the different 
regions on the same side of the chest, and in correspond- 
ing regions on the two sides. In giving an account of 
these variations, based on a series of recorded examina- 
tions in healthy persons, the different regions will be 



NORMAL VOCAL RESONANCE. 80 

considered in the same order as in the study of the varia- 
tions of the respiratory sounds (vide p. 82 et seq.). 

Infra-clavicular Region. — The vocal resonance in 
this region on either side is more intense than in the 
anterior regions below, the intensity, however, in differ- 
ent persons being very variable. Irrespective of inten- 
sity, it is less diffused nearer the ear, and the pitch is 
somewhat higher. These latter variations are marked 
chiefly in the sterno-clavicular extremity of the region, 
that is, over the site of the primary bronchi. In some 
persons the concentration, nearness to the ear and eleva- 
tion of pitch, especially on the right side, are such as to 
approximate the normal resonance to the morbid sign 
called bronchophony. The characters of this sign will 
be considered in the next chapter, but it is important 
to know that exceptionally these characters may be, in 
a measure, illustrated in health in the infra- clavicular 
region. The resonance may then be termed normal 
bronchophony. 

A comparison of the resonance in the region on the 
right side and on the left side always shows a disparity. 
The resonance on the right side is invariably greater. 
The degree of difference between the two sides varies in 
different persons. The resonance may be more or less 
marked on the right and nearly wanting on the left 
side. Allowance is to be made for the points of normal 
disparity between the two sides in the diagnosis of dis- 
ease ; hence the student must become practically fami- 
liar with them. 

The vocal vibration or fremitus varies fully as much 
as the vocal resonance in different persons. Its inten- 
sity is not always proportionate to that of the resonance ; 
that is, the resonance may he comparatively weak when 



90 AUSCULTATION IN HEALTH. 

the fremitus is strong, and vice versa. The fremitus, 
like the resonance, is always greater on the right than 
on the left side, the disparity, like that of the resonance, 
varying considerably in different persons. 

Scapular Region. — The resonance iu this region is 
notably less intense than in the infra-clavicular region. 
It is also more diffused and distant. The intensity is 
always greater on the right side. These statements arc 
alike applicable to the vocal fremitus. 

Infer- scapular Region. — The intensity of the resonance 
here is nearly or quite as great as iu the sterno-clavicu- 
lar extremity of the infra-clavicular region. The reso- 
nance has iu some persons in this region the characters 
of bronchophony. The intensity is always greater on 
the right side. The fremitus is more or less marked, 
and always more marked on the right than on the left 
side. 

Infra-scapular Region. — As a rule, the resonance in 
this region is stronger than over the scapula. It is 
always characterized by diffusion and distance. As iu 
all the regions, it varies much in different persons, and 
is stronger on the right thau ou the left side. These 
statements are also applicable to fremitus. 

Mammary and Infra-mammary Regions. — The reso- 
nance is notably less thau at the summit of the chest. 
The characters of bronchophony are never present. The 
intensity is greater on the right side. The same is true 
of fremitus. 

Axillary and Infra-axillary Regions. — The resonance 
in these regions, and especially in the axillary region, 
is greater than over the mammary and infra-mammary 
regions. It is, of course, stronger on the right side. 
The characters as contrasted with those of bronchophony, 



NORMAL BRONCHIAL WHISPER. 91 

namely, distance and diffusion, are marked. Fremitus 
is more or less marked, and, of course, more marked 
ou the right than on the left side. 

Normal Bronchial Whisper. 

Prior to the publication of the author's work on the 
"Physical Exploration of the Chest," in 1856, signs in 
health and disease relating to the whispered voice had 
received but little attention. In that work, and more 
fully in the second edition, published in 1866, a series 
of signs accompanying whispered words were described 
and named. As a point of departure for the study of 
the morbid signs thus obtained, of course the signs in 
health must first be studied. The sounds which are 
heard over different parts of the chest in health I have 
embraced under the name, the normal bronchial whisper. 
The pertinency of this name is derived from the fact 
that the conduction of the sound produced by the whis- 
pered voice must be chiefly by the air contained in the 
bronchial tubes. The sound heard over the trachea 
and larynx may be distinguished as the laryngeal or 
tracheal whisper, the characters of which have been 
already stated (vide page S(i). 

ft will facilitate the study of the normal bronchial 
whisper, as well as of the morbid signs, to consider 
that the characters of the sounds produced with the 
whispered voice are identical with those produced by 
the act of expiration in all respects save intensity. 
Whispered words are produced, as a rule, by an act of 
expiration, the sounds being more intense generally 
than those which accompany even forced breathing. 
Curiously enough, there are exceptions to this rule. 



92 AUSCULTATION IN HEALTH. 

Some persons insist upon whispering with the act of 
inspiration, and there are some persons who have never 
acquired the ability to whisper. It will be at once 
evident that the pitch and quality of sounds produced 
by whispered words with the act of expiration must 
be the same as those of the sounds of expiration m 
breathing. 

Selecting for the study of the normal bronchial whisper 
the same situations as in commencing the study of the 
normal respiratory murmur, and the normal vocal re- 
sonance, namely, the middle of the chest in front, on the 
right side, and the infra-scapular region behind : with 
t^e whispered voice in these situations is heard, in most 
persons, a feeble, low-pitched blowing sound, these 
characters corresponding to those of the expiratory 
sound in forced breathing. The normal bronchial 
whisper in these situations is not in all persons appre- 
ciable. 

In the infra-clavicular region, the bronchial whisper 
is heard, with variable intensity, in most persons. It 
is somewhat higher in pitch than the whisper below 
this region. It is louder and higher in the sterno- 
clavicular than in the acromial extremity. In the 
former situation it has not infrequently a tubular 
quality. It is louder on the right than on the left 
«ide of the chest. It is sometimes heard on the right 
when it is inappreciable on the left side. When heard 
on both sides the pitch of the sound is higher on the 
left than on the right side. It will be observed that 
these variations correspond to those of the sound with 
expiration in the infra-clavicular region (vide page 89). 
Occasionally whispered words are partly transmitted, 
constituting incomplete whispering pectoriloquy. 



NOEMAL BRONCHIAL WHISPER. 93 

In the scapular region the bronchial whisper is not 
infrequently wanting. It may be present on the right 
and not on the left side, and if present on both sides, it 
is always louder on the right side. 

In the inter-scapular region, as a rule, it is nearly or 
quite as marked as over the site of the primary bronchi 
in front. The pitch is more or less high, and has a 
tubular quality. It is louder on the right and higher 
in pitch on the left side, and in this situation there may 
be incomplete pectoriloquy. 

In the infra-scapular region it is not infrequently 
wanting. When present it is generally feeble, the pitch 
being low and the quality non-tubular, or blowing. It 
is oftener wanting on the left than on the right side, 
and, if present on both sides, it is louder on the right 
side. 

In the mammary and infra-mammary regions it is 
not infrequently wanting, and the statements just made 
with reference to the infra-scapular region are alike ap- 
plicable to these, as, also, to the axillary and infra-axil- 
lary regions. 



5* 






CHAPTER V. 

AUSCULTATION IN DISEASE. 

The respiratory signs of Disease : Abnormal modifications of the normal 
respiratory sounds : — Increased vesicular murmur — Diminished vesic- 
ular murmur— Suppressed respiratory sound— Bronchial or tubular 
respiration— Broncho-vesicular respiration — Cavernous respiration — 
Broncho - cavernous respiration — Vesiculocavernous respiration — 
Amphoric respiration— Shortened inspiration— Prolonged expiration 
— Interrupted respiration. Adventitious respiratory sounds or rales. 
Laryngeal or tracheal rales — Moist bronchial rales, coarse, fine, and 
subcrepitant— Vesicular or crepitant rale— Cavernous or gurgling rale 
—Pleural friction rales, metallic tinkling and splashing— Indeter- 
minate rales. The vocal signs of disease: Bronchophony —Whispering 
bronchophony — iEgophony — Increased vocal resonance —Increased 
bronchial whisper — Cavernous whisper — Pectoriloquy— Amphoric 
voice or echo— Diminished and suppressed vocal resonance— Dimin- 
ished and suppressed vocal fremitus- Metallic tinkling. Signs ob- 
tained by acts of coughing or tussive sounds. 

The importance of becoming perfectly familiar with 
the signs of health before entering upon the study of 
morbid signs, cannot be too strongly enforced. The 
auscultatory signs of disease, which are to be considered 
in this chapter, should not be studied until the student 
has made himself complete master of all the characters 
belonging to the normal signs obtained by auscultation. 

Auscultation in disease embraces the signs produced 
by respiration, by the voice, and by acts of coughing. 
The respiratory signs will be first considered. 

The Respiratory Signs of Disease. 

The morbid signs produced by respiration may be 
classified as follows : 1st. Those which are abnormal 



MODIFICATIONS OF NORMAL SOUNDS. 95 

modifications of the normal respiratory sounds. 2d. 
Those which have no analogues in health, being entirely 
new or adventitious sounds. The latter are usually 
embraced under the name r&les. 

Abnormal Modifications of the Normal Respiratory 
Sounds. 

In order to appreciate the distinctive characters of the 
signs embraced in this class, the characters which dis- 
tinguish the normal vesicular murmur must be kept in 
mind. The abnormal modifications which characterize 
these morbid signs relate to intensity, pitch, and quality 
of sound, together with certain alterations in rhythm. 
Twelve signs are included under this heading, namely : 
1. Increased vesicular murmur ; 2. Diminished vesicu- 
lar murmur ; 3. Suppression of respiratory sound ; 4. 
Bronchial or tubular respiration ; 5. Broncho-vesicular 
respiration ; 6. Cavernous respiration ; 7. Broncho- 
cavernous respiration ; 8. Vesiculocavernous respira- 
tion ; 9. Amphoric respiration ; 1.0. Shortened inspira- 
tion ; 11. Prolonged expiration; and, 12. Interrupted 
inspiration. 

These signs are to be studied, first, with reference to 
their distinctive characters severally, each being con- 
trasted, as respects these characters, with the other mor- 
bid respiratory signs as well as with the normal vesicu- 
lar murmur ; and, second, with reference to the morbid 
physical conditions which they severally represent, that 
is, the diagnostic significance which belongs to each. 

Increased Vesicular Murmur. — This sign has but a 
single distinctive character, namely, increase of intensity. 
The murmur is abnormally loud, the characters of the 



i 



9fi AUSCULTATION IN DISEASE. 

normal vesicular murmur being in other respects not 
materially changed, that is, the pitch is low and the 
quality vesicular as in health. Now, it has been seen 
(vide page 81) that the intensity of the healthy murmur 
varies much in different persons ; there is no ideal 
standard of normal intensity by reference to which an 
abnormal increase is to be determined. Yet the in- 
crease under certain conditions of disease is such that the 
fact is sufficiently evident. It occurs on the healthy 
side of the chest when the respiratory function on the 
other side is annulled or much compromised by disease. 
This takes place in cases of pleurisy with large effusion, 
pneumonia, especially if more than one lobe be affected, 
obstruction of one of the primary bronchi, and pneumo- 
thorax. The sign does not possess great diagnostic 
importance inasmuch as the nature and extent of the 
disease are ascertained by the signs obtained on the 
affected side. 

The sign has been called supplementary and for the 
reason that it occurs normally in childhood, puerile 
respiration. 

If the murmur be much intensified, it may possibly 
be mistaken for other morbid signs, namely, bronchial 
or broncho-vesicular respiration. This error, however, 
can never be made if the distinctive characters of these 
signs relating to pitch and quality have been correctly 
studied. 

Diminished Vesicular Murmur. — The intensity of the 
vesicular murmur may be on the one hand diminished 
when it is evident that in other respects there is no mate- 
rial change, and the murmur, on the other hand, may 
become so feeble that characters aside from the intensity 
are not determinable. From the latter fact it follows 



MODIFICATIONS OF NORMAL SOUNDS. 97 

that the murmur must sometimes be considered as only 
weakened, when, were the diminished intensity not as 
great, morbid changes in pitch and quality might be 
appreciable. 

This is known as the indeterminate respiratory mur- 
mur, that is, when its characters aside from intensity 
cannot be made out. 

The murmur is more or less weakened in cases of 
dilatation of the air-cells, or vesicular emphysema, the 
sign, in these cases, being ofteu accompanied by changes 
in rhythm, namely, a shortened inspiration and a pro- 
longed expiration. Simple weakness of the murmur 
may also be incident to partial blocking of the air-vesi- 
cles with blood or serum in cases of pulmonary extra- 
vasation and oedema. A deficient expansion of the 
chest, either on one side or on both sides, occasions 
weakness of the respiratory murmur. Deficient expan- 
sion of one side, or of both sides, may be caused by 
paralysis, bilateral- or unilateral, of the costal muscles. 
A similar effect is caused by paralysis of the diaphragm. 
The incomplete descent of the diaphragm from pain, as 
in peritonitis, or from mechanical obstacles, as in perito- 
neal dropsy, pregnancy, and abdominal tumors, weakens 
the respiratory murmur, the increased action of the 
costal muscles not being fully compensatory. Unilateral 
deficiency of expansion of the chest is caused by pain in 
intercostal neuralgia, pleurodynia, acute pleurisy, and 
pneumonia; it is also caused by the presence of a stra- 
tum of liquid, aii", or a thick layer of lymph between 
the lung and the chest-wall in pleurisy, hydrothorax, 
and pneumothorax. Swelling of the bronchial mucous 
membrane in bronchitis affecting the larger tubes, must 
diminish somewhat the intensity of the murmur. In 






98 



AUSCULTATION IN DISEASE 



primary bronchitis the murmur is diminished on both 
sides In bronchitis affecting the smaller tubes the 
murmur is greatly diminished, if not suppressed, on 
both sides. Incomplete obstruction of bronchial tubes 
from the presence of mucus, serum, blood, or pus has 
this effect over an area corresponding to the size ot the 
tubes obstructed. Spasm of the bronchial muscular 
fibres in paroxysms of asthma, diminishes, if it do not 
suppress, murmur on both sides. Another cause of 
diminution, unilateral, or within a limited space on one 
side is the pressure of a tumor pressing on bronchial 
tubes, as in cases of aneurism. A permanent contrac- 
tion or stricture of bronchial tubes is another cause. 
Not infrequently the pressure of an aneunsmal tumor 
or an enlarged bronchial gland on a primary bronchus, 
occasions notable weakness of the murmur oyer the 
whole of one side ; and the pressure of a tumor on he 
trachea weakens the murmur, more or less, or both sides. 
A foreign body in one of the primary bronchi weakens 
it on the corresponding side. Diminution of the calibre 
of the trachea or larynx from morbid growths, the 
presence of foreign bodies, fibrinous exudations, accumu- 
lations of mucus, submucous infiltration, spasms of the 
laryngeal muscles, and swelling of the mucous mem- 
brane: weakens, in proportion to the amount of obstruc- 
tion, the murmur on both sides without any material 
change in its quality and pitch. 

Weakened murmur at the summit of chest, without 
other appreciable abnormal characters, occurs in some 
eases of phthisis, due to obstructed bronchial tubes from 
coexisting circumscribed bronchitis, or to deficient supe- 
rior costal movements of the chest, as well as to the 
presence of exudation in the air-vesicles. 



MODIFICATIONS OF NORMAL SOUNDS. 99 

Diminished intensity of the vesicular murmur is thus 
seen to be a respiratory sign entering into the diagnosis 
of a considerable number of diseases, namely, emphysema, 
paralysis affecting the respiratory muscles, asthma, ab- 
dominal affections interfering with the diaphragmatic 
movements, intercostal neuralgia, pneumonia, hydro- 
thorax, bronchitis, aneurismal and other tumors, per- 
manent constriction or stricture of bronchial tubes, 
laryngitis, oedema of the glottis, spasm of the glottis, 
the various lesions which occasion obstruction of the 
larynx or trachea, and phthisis. 

In determining a slight abnormal weakness of the 
respiratory murmur at the summit of the chest on the 
right side, the normal disparity between the two sides 
in this situation is to be borne in mind. The vesicular 
murmur is normally less intense on the right than on 
the left side. 

This sign occurring in so many diseases, it is obvious 
that, taken alone, that is, independent of other signs, it 
has not any special diagnostic significance. It is, how- 
ever, often of value in diagnosis, when taken in con- 
nection with other signs. It is chiefly useful when it 
exists either over the whole or in a part of the chest on 
one side. 

Suppressed Respiratory Sound. — This sign is easily 
defined, namely, absence of all respiratory sound, as the 
name signifies. It cannot, of course, have any characters 
relating to intensity, pitch, and quality. 

Suppression of respiratory sound represents the same 
physical conditions as diminished vesicular murmur; 
the physical conditions represented by the latter sign, 
existing in a greater degree, occasion absence of all 
sound. It sulliees, therefore, to recapitulate the various 






100 AUSCULTATION IN DISEASE. 

conditions and diseases in connection with which the 
murmur may either be diminished or suppressed. Sup- 
pression over portions of the chest may be due to dilata- 
tion of the air-cells in cases of emphysema. It occurs 
from the exclusion of air from the vesicles by the 
presence of blood and serum in cases of pulmonory 
extravasation and oedema. Respiratory sound is some- 
times wanting over lung solidified in cases of pneumonia 
and phthisis. Paralysis of the muscles concerned in 
respiration may possibly involve feebleness of the respi- 
ratory acts sufficiently to render the murmur inappreci- 
able. In intercostal neuralgia, pleurodynia, acute pleu- 
risy, and pneumonia, the movements of the affected side 
may be so much restricted as to abolish the murmur. 
Tn pleurisy with much effusion, empyema, hydrothorax, 
pneumothorax, the murmur is suppressed over either a 
part or the whole of the affected side, the extent of the 
suppression corresponding to the quantity of serum, pus, 
or air within the pleural cavity. Swelling of the mucous 
membrane in cases of bronchitis affecting the larger 
bronchial tubes is never sufficient to suppress the mur- 
mur, but plugging of more or less of the tubes with 
mucus or other morbid products may have this effect. 
In cases of bronchitis, the murmur is sometimes found 
to have disappeared over a certain area, and to return 
after an act of expectoration. In bronchitis affecting 
the smaller tubes, suppression of the murmur is not in- 
frequent. It occurs from spasm of the bronchial mus- 
cular fibres in cases of asthma. The pressure of a tumor, 
morbid growths, or deposits from bronchi within the 
lungs, may abolish respiratory sound over a portion of 
the chest, and permanent stricture or obliteration of 
bronchial tubes may have this effect. Tuberculous, 



_ 



MODIFICATIONS OF NORMAL SOUNDS. 



101 



carcinomatous, and sarcomatous infiltrations of pul- 
monary tissue abolish the vesicular murmur. Respira- 
tory sound may be suppressed over the whole of one 
side from the pressure of an aneurismal or some other 
tumor upon one of the primary bronchi. If the tumor 
press upon the trachea, the obstruction may be sufficient 
to suppress the murmur on both sides. A foreign body 
lodged in a primary bronchus may suppress the murmur 
on the corresponding side, and, lodged in the larynx or 
trachea, the murmur may be suppressed on both sides. 
The different affections of the larynx and trachea which, 
in proportion to the amount of obstruction, weaken the 
murmur, may render it inappreciable. 

Bronchial or Tabular Respiration, — The analogue of 
this sign is the normal laryngeal or tracheal respiration 
{vide page 79). The characters which distinguish the 
latter normal sign from the normal vesicular murmur 
are those which are distinctive of the bronchial or 
tubular respiration. These characters, relating to the 
inspiratory and the expiratory sounds, are as follows : 
The inspiratory sound is of variable intensity. Inten- 
sity does not enter into the distinctive characters of this 
sign ; the sound may be either louder or weaker than 
the inspiratory sound in health. The pitch of the in- 
spiratory sound is high. The quality is expressed by 
the term tubular. It is like the. sound produced by 
blowing through a tube, this quality taking the place 
of that expressed by the term vesicular in the normal 
respiration. The expiratory sound is prolonged; it is 
as long as, or longer than, the sound of expiration, and 
is usually louder. The pitch is still higher than that of 
the inspiratory sound. The quality, like that of the in- 
spiratory sound, is tubular, this quality taking (he place 



102 AUSCULTATION IN DISEASE. 

of the simple blowing quality of the expiratory sound in 
the normal vesicular murmur. With the normal rhythm 
of the respiratory acts there is a very brief interval be- 
tween the sounds of inspiration and expiration, due to 
the fact that the inspiratory sound ends a little before 
the end of the inspiratory act. 

The morbid physical condition represented by this 
important sign is either complete or considerable solidi- 
fication of lung. Whenever the chest is auscultated over 
lung solidified, if there be not absence of respiratory 
sound, the sound is tubular. This significance renders 
the sign of diagnostic value in the diseases which involve 
solidification. The sign per se denotes simply this mor- 
bid physical condition; the particular disease which exists 
is ascertained by means of the associated signs and the 
symptoms. 

Solidification of lung is incident to several different 
diseases. In lobar pneumonia it is due to a fibrinous 
exudation within the air-vesicles. In phthisis it is 
caused by an exudation in the same situation. In 
chronic or fibroid pneumonia the lung is solidified by 
an interstitial growth. Tuberculous, carcinomatous, 
and sarcomatous infiltrations likewise cause obliteration 
of the air-vesicles and corresponding solidification. The 
compression of lung from cither pleuritic effusion, an 
accumulation of air in the pleural cavity, or the pressure 
ot a tumor, causes solidification by condensation. Col- 
lapse of pulmonary lobules also solidifies by condensa- 
tion. Coagulation of blood within the air- vesicles 
(hemorrhagic infarctus) is another cause of solidifica- 
tion. In these different affections, if the solidification 
be complete or considerable, this sign is usually present; 



L 



MODIFICATIONS OF NORMAL SOUNDS. 103 

it is always present if there be not suppression of respi- 
ratory sound. 

It is sometimes the case that either the inspiratory or 
the expiratory sound is wanting. The characters of the 
sign suffice for its recognition if either the inspiratory 
or the expiratory sound be alone present : the pitch and 
the quality are distinctive. Both sounds are often so 
intense that they are diffused more or less beyond the 
limits of the solidified portion of lung. The expiratory 
sound, being more intense than the inspiratory, is trans- 
mitted further than the latter. This explains the con- 
junction sometimes of a vesicular inspiration with a 
tubular expiration ; and a cavernous inspiration may 
be conjoined with a tubular expiration, showing the 
proximity of solidified lung in the former case to healthy 
lung, and, in the latter case, to a pulmonary cavity. 

The sound may seem near the ear or to come from a 
certain distance. The latter is appreciable in some 
cases of large pleuritic effusion : the tubular respiration 
appears to be more or less distant, and it is sometimes 
diffused over the whole of the side which is filled with 
liquid. 

Broncho-vesicular Respiration. — This name was intro- 
duced by me, in 1856, to denote the combination, in 
varying proportions, of the characters of the bronchial 
or tubular, and of the normal vesicular respiration. 
The name expresses such a combination. It embraces 
modifications to which have been applied the terms, 
rude, rough, and harsh respiration, and certain of those 
included by German authors under the name indetermi- 
nate respiratory sounds. 

The sign represents the different degrees of solidifi- 
cation of lung, between an amount so slight as to occa- 



104 AUSCULTATION IN DISEASE. 

sion only the smallest appreciable modification of the 
respiratory sound, and an amount so great as to approxi- 
mate closely to the degree giving rise to bronchial or 
tubular respiration. In other words, all the gradations 
of respiratory modifications caused by incomplete or an 
inconsiderable solidification, which fall short of bron- 
chial or tubular respiration, are embraced under the 
name broncho-vesicular. The gradations correspond to 
the amount of solidification, that is, they show the 
solidification to be either very slight, slight, moderate, 
or nearly sufficient to be considered as considerable or 
complete. The sign is, therefore, important as evidence, 
first, of the existence of solidification ; aud, second, of 
the degree of solidification. 

Analyzing this sign, the most distinctive feature is the 
combination of the vesicular and the tubular quality in 
Hie inspiratory sound. These two qualities may be 
combined in variable proportions. The pitch of the 
sound is raised in proportion as the tubular predomi- 
nates over the vesicular quality. The expiratory sound 
is more or less prolonged, tubular in quality, and the 
pitch is raised. The prolongation of this sound, its 
tubular quality, and the highness of pitch, are propor- 
tionate to the predominance of the tubular over the 
vesicular quality in the inspiratory sound. If the solidi- 
fication of lung be slight, the characters of the normal 
vesicular respiration predominate; that is, the inspira- 
tory sound has but a small proportion of the tubular 
quality, and is but little raised in pitch, the expiratory 
sound beiug not much prolonged, its tubularity not 
marked, the pitch not high. If, on the other hand, the 
solidification of lung be almost enough to give a bron- 
chial respiration, the inspiratory sound has only a little 



MODIFICATIONS OF NORMAL SOUNDS. 105 

vesicular quality, the tubular quality predominating, the 
pitch proportionately raised ; and the expiratory sound 
is prolonged, tubular, and high, nearly to the same 
extent as in the bronchial respiration. The less the 
solidification the more the characters of the normal 
vesicular predominate over those of the bronchial respi- 
ration, and, per contra, the greater the solidification the 
more the characters of the bronchial predominate over 
those of the normal vesicular respiration. Daily aus- 
cultation in a case of lobar pneumonia during the stage 
of resolution affords an opportunity to study all the 
gradations of this sign. After resolution has made 
some progress the inspiratory sound is no longer purely 
tubular, but the ear appreciates a little admixture of 
the vesicular quality and the pitch is slightly lowered. 
As resolution goes on the vesicular quality increases, 
the pitch is correspondingly lowered, until, at length, 
no tubularity remains, and the pitch becomes normal. 
Meanwhile, as the vesicular quality increases in the 
inspiratory sound, the expiratory sound is less and less 
prolonged, high and tubular, until it becomes, as in 
health, short, low, aud blowing. 

The broncho-vesicular respiration is an important 
diagnostic sigu in all the affections which involve par- 
tial solidification of lung. In lobar pneumonia, as just 
stated, it denotes the progress made from day to day in 
resolution. It is found also in an earlier stage, before 
the solidification is sufficient to give rise to a purely 
bronchial respiration. It is a valuable sign in phthisis, 
affording evidence, not only of the fact of solidification, 
but of its degree and extent. The signs enter into the 
diagnosis of interstitial pneumonia, hemorrhagic infarc- 
tus, condensation of lung from the pressure of either 



106 AUSCULTATION IN DISEASE. 

liquid, air, or a tumor, and from collapse of pulmonary 
lobules. It may be stated with respect to this sign, 
that it is always present if the lung be partially solidi- 
fied, provided there be not either suppression of respi- 
ratory sound, or such a degree of feebleness that the 
distinctive characters are undeterminable. As with the 
bronchial respiration, so with the broncho-vesicular, 
either the inspiratory or the expiratory sound may be 
wanting. The characters of the sign are then to be 
determined as they are manifested in the sound which 
is present, namely, the combination of the vesicular and 
the tubular quality, with more or less elevation of 
pitch, if only an inspiratory sound may be heard, and 
the amount of prolongation, tubularity, and elevation 
of pitch, if there be only an expiratory sound. 

In determining the presence of this morbid sign at 
the summit of the chest on the right side, it is to be 
borne in mind that the respiratory murmur on this side 
has, in health, as compared with the respiratory mur- 
mur at the summit on the left side, more or less of the 
characters of the broncho-vesicular respiration (vide 
Normal Broncho-vesicular Respiration, page 103). 

Cavernous Respiration. — The modifications which con- 
stitute the distinctive characters of this sign are produced 
by the entrance of air into a cavity with the act of in- 
spiration, and its exit from the cavity with the act of 
expiration. This passage of air into and from a cavity 
can only take place where the walls of the cavity col- 
lapse more or less in expiration and expand in inspira- 
tion. Pulmonary cavities occur chiefly in cases of 
phthisis. They occur, but with comparative infre- 
quency, as a result of circumscribed abscess and gan- 
grene of lung. 



MODIFICATIONS OF NORMAL SOUNDS. 107 

A well-marked cavernous respiration has characters 
which are highly distinctive when this sign is contrasted, 
on the one hand, with either the bronchial or broncho- 
vesicular respiration, and, on the other hand, with the 
normal vesicular murmur. These distinctive characters 
relate both to the inspiratory and expiratory sound. 
The inspiratory sound is neither vesicular nor tubular 
in quality, and the pitch is low as compared with the 
bronchial respiration. As regards quality, we may say 
of it, as of the expiratory sound in the normal vesicular 
respiration, it is simply a blowing sound. The expira- 
tory sound has the same quality as the inspiratory, and 
is lower in pitch. Its duration is variable. The inten- 
sity of both the inspiratory and the expiratory sound 
varies; intensity does not enter into the distinctive char- 
acters of this sign more than into those of the bronchial 
and the broncho- vesicular respiration. These distinctive 
characters of the cavernous respiration, as regards pitch 
and quality, especially of the expiratory sound, were 
first pointed out by me in 1852. * Prior to this date 
the bronchial and the cavernous respiration were con- 
sidered as having identical characters, or at all events, 
as not distinguishable from each other. Following 
Skoda, these two signs are still considered as essentially 
identical by German authors. With a practical knowl- 
edge of the foregoing characters distinctive of the 
cavernous respiration, there is no difficulty in dis- 
criminating this sign from the bronchial respiration. 
The sign is more likely to be confounded with the normal 
vesicular murmur, inasmuch as it differs from the latter 

1 Prize Essay on Variations <>f Pitch in the Sounds obtained by 
Percussion and Auscultation. Transactions of the American Medical 
Association, 1852. 



108 AUSCULTATION IN DISEASE. 

only iu the absence in the inspiratory sound of the vesic- 
ular quality. Against this error the student is to be 
cautioned. It is most likely to be made when the in- 
spiratory sound is much weakened, and, consequently, 
the vesicular quality less distinctly appreciable than 
when the sound is more or less intense. 

A cavernous respiration is limited to a space more or 
less circumscribed, the area corresponding to the site and 
the size of the cavity. Occurring, for the most part, in 
cases of phthisis, it is much more frequently found at 
the summit than elsewhere over the chest. It is not 
constantly found where there is a cavity with flaccid 
walls. It may be temporarily suppressed by the 
presence of liquid within the cavity, and by obstruction 
of the orifices communicating with bronchial tubes, or 
of the latter. It may be wanting at one moment, and 
an act of expectoration may cause it to reappear. Hence 
absence of cavity cannot be predicated on the absence of 
the sign at a single examination. Moreover, if a cavity 
be not situated near the pulmonary superficies, and solidi- 
fied lung intervene between it and the walls of the chest, 
the cavernous sign may be drowned in a loud bronchial 
respiration. For this reason, while the cavernous sign 
is positive evidence of a cavity, the absence of the sign 
is not proof that a cavity does not exist. 

In some cases of perforation of lung with pneumo- 
thorax, the passage of air to and fro through the per- 
foration may give rise to the cavernous respiration. 
As a rule, however, under these circumstances, another 
sign is produced, namely, the amphoric respiration. 

The cavernous respiration may be reproduced by the 
inflation of the lungs after their removal from the body, 
the binaural stethoscope being placed over a cavity. 



MODIFICATIONS OF NORMAL SOUNDS. 109 



This is true, also, of the bronchial and the broncho- 
vesicular respiration. These signs may be thus illus- 
trated not infrequently after death from phthisis, in 
lungs in which are cavities together with portions com- 
pletely or moderately solidified. 

The distinctive characters of the cavernous respiration 
may also be illustrated by means of a small India-rubber 
balloon with an opening at opposite ends. Inflating the 
balloon through a tube introduced into one opening pro- 
duces a sound analogous to the cavernous inspiration, 
and the expulsion of the air by the elasticity of the 
balloon produces a sound analogous to the cavernous 
expiration. A Davidson's syringe may be used to inflate 
the balloon. The sounds are heard by applying lightly 
to the balloon the binaural stethoscope. This illustra- 
tion demonstrates the mechanism of the cavernous respi- 
ration. 

Broncho-cavernous Respiration. — In this sign, as the 
name denotes, the characters of the bronchial and the 
cavernous respiration are combined. These characters 
maybe combined in different ways, as well as in variable 
proportions. If a cavity be situated in proximity to 
solidified lung, the quality and pitch of the inspiratory 
and the expiratory sound may show an admixture of the 
characters of the two signs, and to a practised ear the 
combination is distinctly recognizable. This is one of 
the forms of broncho-cavernous respiration ; the sounds 
are not sufficiently high and tubular for bronchial, nor 
sufficiently low and blowing for cavernous respiration. 
Another form consists of an inspiratory sound, the first 
part of which is tubular, and the latter part cavernous. 
Examples of this form are not extremely infrequent. 
This form has been recently described by Seitz under 
6 



HO AUSCULTATION IN DISEASE. 

the name " metamorphosing respiration." Still another 
form is a cavernous inspiratory, with a bronchial or 
tubular expiratory sound. In the latter form, the bron- 
chial expiration proceeds from solidified lung situated 
near the cavity, the intensity of the sound being suffi- 
cient to drown the cavernous expiration. 

When as often happens, a cavity is situated in close 

proximity to, or, it may be, surrounded by solidified 

king the cavernous and the bronchial respiration are, as 

it were in juxtaposition, and such instances offer an 

excellent opportunity to study the points distinguishing 

these signs from each other; and, generally, at a short 

di<tance & the normal vesicular murmur may be found, so 

that both morbid signs may be compared with the latter 

Within a circumscribed area sometimes are exemplified 

the characters of the normal murmur, and of the two 

morbid signs just mentioned, together with those of the 

broncho-vesicular respiration. 

Vesimlo-eavemous Respiration. -It is sometimes evi- 
dent that the vesicular and the cavernous quality are 
combined in the inspiratory sound. This occurs when 
, cavity is surrounded, not by solidified, but by healthy 
lung ' Under these circumstances, over the site of the 
cavity the inspiratory sound may be as loud as, or louder 
than, that around the cavity, but the quality is not 
purely cavernous ; some vesicular quality is appreci- 
able A vesiculocavernous respiration, then, is a 
cavernous respiration plus some vesicular quality de- 
rived from the air-vesicles which are proximate to the 
cavity This sign is corroborated by other associated 
signs showing the existence of a cavity and its localiza- 



tion. 



MODIFICATIONS OP NORMAL SOUNDS. Ill 

Amphoric, Respiration. — The term amphoric has a 
significance when applied to auscultatory sounds, anal- 
ogous to that which it has in percussion ; it denotes a 
musical intonation which may be compared to the sound 
produced by blowing upon the open mouth of a decan- 
ter or phial. Whenever the respiratory sound has this 
intonation, it denotes a space containing air which is not 
expelled with the act of expiration. Air in the pleural 
cavity with perforation of lung, is the physical condition 
most frequently represented by this sign. It is a valu- 
able diagnostic sign in cases of pneumothorax ; but it is 
not always present in that affection, certain accessory 
conditions being requisite, namely, perforation above 
the level of liquid, and an unobstructed communication 
ot the bronchial tubes, through the opening, with the 
pleural space containing air. While, therefore, its 
presence may be significant of pneumothorax, its absence 
is by no means sufficient to exclude this affection. Not 
infrequently it is a sign of a phthisical cavity with rigid 
walls which do not collapse with the act of expiration. 
The same contingencies affect its production here as in 
cases of pneumothorax. Whenever amphoric respiration 
is present, if pneumothorax be excluded by the absence 
of the other signs which are diagnostic of this affection, 
the sign is proof of the existence of a pulmonary cavity, 
the walls of which are not flaccid. The sign then takes 
the place of the ordinary cavernous respiration which 
has been described. 

The amphoric sound may accompany either inspira- 
tion or expiration, or both. Amphoric respiration may 
be artificially illustrated by connecting an India-rubber 
bag of considerable size (such as is contained within a 
foot-ball) with a flexible tube, and after dilating it with 



112 AUSCULTATION IN DISEASE. 

air, inflating it forcibly either by a pair of bellows or 
by the mouth, holding the bag close to the ear. The 
amphoric sound thus produced represents the amphoric 
respiration as a sign in pneumothorax. As the sign of 
a tuberculous cavity it may be illustrated by a similar 
experiment, using an India-rubber bag of the size of an 
egg or orange. I have localized a tuberculous cavity 
with rigid walls in the centre of a lobe, by inflating 
artificially phthisical lungs after their removal from the 
body. 

Shortened Inspiration. — The inspiratory sound is 
somewhat shortened in bronchial or tubular respiration. 
This modification enters into the characters of that sign, 
the quality of the sound being tubular, and the pitch 
high. The shortening is due to the sound ending before 
the inspiratory act ends; the sound is said to be un- 
finished. Shortening of the sound occurs, however, 
when it is not an element in the bronchial respiration. 
The shortening is then due to the sound not beginning 
with the inspiratory act ; this is distinguished as deferred 
inspiratory sound. A deferred inspiratory sound not 
tubular in quality, but more or less vesicular, and not 
notably raised in pitch, is a sign of pulmonary or 
vesicular emphysema. It is a sigu of value in connec- 
tion with the diagnosis of that disease. 

The student should note the distinctions just stated 
which relate to pitch and quality. Suppose an inspira- 
tory sound to be present without an expiratory sound ; 
if the sound be shortened at the end of the inspiration, 
the pitch high, and the quality tubular, it is bronchial 
respiration, denoting complete or considerable solidifica- 
tion of lung, but if the shortening be at the beginning 
of respiration, the pitch comparatively low, and vesicu- 



MODIFICATIONS OF NORMAL SOUNDS. 



113 



lar quality be appreciable, the sign denotes emphysema. 
The differential points thus are, the inspiratory sound 
either unfinished or deferred, the pitch either high or 
low, and the quality either tubular or vesicular. Atten- 
tion to these points is essential in order to avoid error 
in the interpretation of the sign. 

Prolonged Expiration. — The length of the expiratory 
sound in health varies in different persons. The sound 
is sometimes considerably prolonged ; it may be nearly 
as long as the sound of inspiration. There is no diffi- 
culty in recognizing this as a normal peculiarity, from 
the fact that the murmur has the pitch and quality of 
health. An unusual length of the expiratory sound, 
within the range of health, is usually observed at the 
summit of the chest, and especially on the right side. 
It is impartant to bear in mind that at the summit of 
the chest on the right side, and sometimes also on the 
left side, a prolonged expiratory sound, more or less 
raised in pitch, and tubular in quality, may be a normal 
peculiarity. It follows that a prolonged, and even a high 
and tubular expiration at the summit of the chest, must 
not be reckoned as a morbid sign unless it be associated 
with other signs denoting disease. The laws of the 
disparity between the two sides of the chest at the sum- 
mit are to be taken into account (vide p. 83). If the 
expiration be longer on the left than on the right side, 
it is abnormal; so, also, is a high-pitched tubular expi- 
ration heard on the left and not on the right side. 

The significance of au abnormally prolonged expira- 
tion depends on its pitch and quality. If it be high and 
tubular, it denotes solidification of lung. It is in fact, 
bronchial respiration. As already stated, in bronchial 
or tubular respiration the inspiratory sound is sometimes 



114 AUSCULTATION IN DISEASE. 

wanting, and the presence of the sign is then to be 
determined by the characters, relating to pitch and 
quality, of the expiratory sound. The same statement 
holds true with respect to broncho-vesicular respiration 
when this approximates to the bronchial. At the sum- 
mit of the chest, the characters of the inspiratory sound, 
and associated morbid signs, always enable the ausculta- 
tor to determine whether a prolonged high and tubular 
expiration be, or be not, abnormal. A prolonged ex- 
piration, which is low in pitch and blowing in quality, 
that is, with the characters of health, aside from length, 
may belong to a cavernous expiration. This is to be 
determined by the characters of the inspiration, and by 
other associated signs. Exclusive of cavernous respira- 
tion, an abnormally prolonged expiratory sound of low 
pitch and non-tubular, denotes vesicular emphysema. 
It is associated then with a weakened and deferred 
inspiratory sound. A prolonged expiratory sound, in 
cases of emphysema, is invariably low and non-tubular. 
If it have not these characters, it is not a sign of emphy- 
sema, but belongs to bronchial or broncho-vesicular 
respiration. Attention to these differential points is to 
be enjoined upon the student. 

A prolonged expiration at the summit of the chest on 
the right side is sometimes incorrectly considered to be 
evidence of phthisis. It is to be recollected, in the first 
place, that prolongation of this sound with a normal 
pitch and quality, is never evidence of solidification of 
lung either from phthisis or any other disease ; and in 
the second place, even if the pitch be high, and the 
quality tubular, that it is not to be regarded as abnormal 
provided the inspiratory sound is unchanged and other 
signs of disease are not present. At times in bronchitis 



MODIFICATIONS OF NORMAL SOUNDS. 115 

there is a prolonged expiratory sound which may be 
distinguished as a sonorous expiration, not amounting 
to a r&le. This is liable to be mistaken for broncho- 
vesicular breathing. 

The importance of observing the pitch and quality of 
a prolonged expiration was pointed out in my work on 
" Physical Exploration/' in 1856. The difference as 
regards the significance of a high pitch with a tubular 
quality from a low pitch with a simply flowing quality, 
has not, as yet, received from medical writers the atten- 
tion which it claims. 

Interrupted Respiration. — To this sign have been ap- 
plied other names, such as jerking, wavy, cogged-wheel, 
and by French writers the names entreooupee and saccadee. 
The modification is either of the inspiration or of the 
expiration, or of both. The inspiratory, however, much 
more frequently than the expiratory, sound is inter- 
rupted. The sound, instead of being continuous, is 
broken into one, two, or more parts. This is the 
characteristic of the sign. If at the same time there be 
alterations in pitch and quality, the interruption is 
merely incidental to other signs, namely, the bronchial, 
broncho-vesicular, or cavernous respiration. To consti- 
tute it a distinct sign, the interruption must be the only 
appreciable change. As a distinct sign it has but little 
diagnostic value. 

Interrupted respiration is sometimes found in healthy 
persons. It is confined to the summit of the chest, and 
oftener on the left than on the right side. Existing 
without any other signs, therefore, it is not evidence of 
disease. It is of value only in the diagnosis of phthisis. 
Associated with other signs, when the latter are not 



116 AUSCULTATION IN DISEASE. 

marked, it is entitled to a certain amount of weight in 
the diagnosis. 

Interrupted respiratory sounds, of course, occur when 
there is interruption in the respiratory movements. 
This happens in cases of pleurisy, pleurodynia, or inter- 
costal neuralgia. Owing to the pain caused by the 
movements in respiration, the patient may breathe, not 
continuously, but with a series of jerking movements. 
Sometimes interrupted breathing is observed in persons 
who are excited or agitated when auscultation is prac- 
tised. In all these instances interruption in the respira- 
tory sounds is found over the whole chest, whereas, 
when it is an abnormal sign in cases of phthisis, it is 
limited to the summit on one side of the chest, and 
there is no interruption manifested in the mode of 
breathing. 

Reviewing the foregoing signs, they may be distributd 
into three classes, as follows : 1st. Signs, the distinctive 
characters of which relate to either the absence or the 
intensity of sound. This class embraces, (a) increased 
intensity of the vesicular murmur; (b) diminished in- 
tensity of the vesicular murmur ; and (c) suppression 
of respiratory sound. 2d. Signs, the distinctive char- 
acters of which relate especially to pitch and quality. 
In this class belong, (a) bronchial or tubular respiration ; 
(b) broncho-vesicular respiration; (c) cavernous respira- 
tion ; (d) broncho-cavernous respiration ; (e) vesiculo- 
cavernous respiration ; and (f) amphoric respiration. 
3d. Signs, the distinctive characters of which relate 
especially to rhythm, namely, (a) shortened inspiration ; 
(b) prolonged expiration ; and (c) interrupted inspiration. 



ADVENTITIOUS RESPIRATORY SOUNDS. 117 



Adventitious Respiratory Sounds, or Rales. 

Adventitious respiratory sounds, or, adopting the 
French term, rales, are distinguished from the morbid 
signs already considered, by the fact that they have no 
analogues in health ; in other words, they are not nor- 
mal sounds abnormally modified, but wholly new sounds. 
A convenient classification of these sounds is based on 
the different anatomical situations in which they are pro- 
duced. This classification is as follows : 1st. Laryn- 
geal and tracheal rales ; 2d. Bronchial rales ; 3d. Vesic- 
ular rales ; 4th. Cavernous rales ; 5th. Pleural rales ; 
and, 6th. Indeterminate rales. Compared Math each 
other, as regards their characters, they admit of being 
divided into dry and moist ra,les, the latter being evi- 
dently due to the presence of liquid. 

Laryngeal and Tracheal Rales. — The rales produced 
within the larynx and trachea may be either moist or 
dry. The moist or bubbling sounds are produced when 
mucus or other liquid accumulates in these sections 
of the air-tubes. This occurs frequently in the mori- 
bund state, and the sounds are then known as the 
"death-rattles." When not incident to this state, they 
denote either insensibility to the presence of liquid, as 
in coma, or inability to effect the removal of the liquid 
by acts of expectoration. The sounds are heard at a 
distance. They exemplify, on a large scale, moist or 
bubbling auscultatory sounds which are produced within 
the bronchial tubes. Dry sounds produced within the 
larynx or trachea are caused by spasm of the glottis, 
and by diminution of the calibre, either at or below the 
glottis, from oedema, exudation, the presence of a foreign 
body, or the pressure of a tumor. The dry sounds are 



118 AUSCULTATION IN DISEASE. 

distinguished as whistling, wheezing, crowing, whooping, 
etc. They are heard at a distance, and they also exem- 
plify auscultatory sounds representing analogous con- 
ditions in the bronchial tubes. Characteristic sounds 
produced at the glottis by spasm enter into the diagnosis 
of certain affections, namely, laryngismus, stridulus, 
pertussis, croup, and aneurism involving excitation of 
the recurrent laryngeal nerve. Other sounds are due to 
paralysis of the laryngeal muscles. Again, dry sounds 
produced by stenosis of the trachea from the pressure of 
an aneurismal or other tumor, cicatrization of ulcers, and 
morbid growths, are of diagnostic importance. Although 
audible without auscultation, these different sounds, with 
reference to the precise situation at which they are pro- 
duced, may sometimes be studied with advantage by 
meaus of the stethoscope. They are embraced under 
the name stridor. The respiration, voice, and cough, 
when accompanied by these sounds, are said to be 
stridulous. 

Moist Bronchial Rales. 

The moist bronchial rales are bubbling sounds pro- 
duced in different branches of the bronchial tree. They 
are sounds of which the "tracheal rattles" are an 
exaggerated type. They may be imitated by blowing 
into liquids through tubes differing in size. They may 
also be produced in the lungs of the sheep or the calf, 
after removal from the body, by injecting into the 
bronchi glycerin or some other liquid, and imitating the 
respiratory act by means of a pair of bellows, ausculta- 
tion being practised with the stethoscope applied upon 
the surface of the lung, or with several thicknesses of 
cloth intervening. The bubbles seem to be large or 



MOIST BRONCHIAL RALES, 119 

small, according to the size of the bronchial tubes in 
which they are produced. Apparent differences in the 
size of the bubbles are distinguished by the names coarse 
and fine. In the primary and secondary bronchial 
branches the moist sounds are relatively quite coarse ; 
they are less so in tubes of the third or fourth dimen- 
sions ; in smaller tubes they become fine, and in those 
of minute size they become extremely fine. Extremely 
fine bubbling sounds constitute what has been known as 
the subcrepitant rale, so called because it approaches in 
character to the crepitant rale produced within the air- 
vesicles and bronchioles. We may thus judge the size 
of the bronchial tubes in which the rales are produced 
by their comparative coarseness or fineness. Frequently, 
however, coarse and fine rales are intermingled, and gener- 
ally those which are either coarse or fine are not uniform, 
but appear to be of unequal size. In all the varieties 
of the moist bronchial rales, the bubbling character of 
the sounds is sufficiently distinctive for their recognition. 
The differentiation of the so-called subcrepitant from 
the crepitant rale alone involves some nice points of 
distinction. 

Coarse bubbling rales sometimes occur in acute bron- 
chitis affecting the larger bronchial tubes. Their occur- 
rence is exceptional, because, in general, the mucus 
within the tubes does not accumulate sufficiently and is 
too consistent for the production of bubbling sounds. 
These rales occur in cases in which the mucus is unusu- 
ally thin, and either more abundant than usual or an 
accumulation takes place in consequence of inability to 
expectorate freely. These conditions are wanting in the 
majority of the cases of ordinary acute bronchitis. A 
muco-puruleut liquid in cases of chronic bronchitis is 



120 AUSCULTATION IN DISEASE. 

better suited for the production of bubbling sounds than 
simple mucus. Moreover, coarse rales are heard oftener 
in children than in adults, because the former do not 
voluntarily expectorate as freely as the latter. Serous 
transudation (bronchorrhoea) into tubes of large size may 
give rise to coarse bubbling rales, and also the presence 
of blood in some cases of profuse hemorrhage. In 
bronchitis and bronchorrhoea the rales are heard on both 
sides of the chest. The bubbling rales, whether coarse 
or fine, are heard either with the act of inspiration or of 
expiration, or with both acts. 

Fine bubbling sounds aud the so-called subcrepitant 
rale occur in various pathological connections. The 
characters of the latter are to be borne in mind with 
reference to the discrimination from the crepitant rale. 
The most distinctive character is the moist sound or 
bubbling; this is sufficiently appreciable. Other char- 
acters are, their occurrence frequently, but uot constantly, 
in expiration as well as in inspiration, and the inequality 
of the fine bubbling sounds. 

The so-called subcrepitant rale, existing over the 
chest on both sides, is diagnostic of bronchitis affecting 
the smaller bronchial tubes (capillary bronchitis), when 
taken in connection with other signs and the symptoms. 
The r£le exists on both sides, because this, as well as 
bronchitis affecting the larger tubes, is a bilateral affec- 
tion. The sign is of great practical value in the diag- 
nosis of that variety of bronchitis. The r&le also occurs 
on both sides, and is more or less diffused in pulmonary 
oedema. The connection with the latter affection is 
shown by the associated physical signs, together with 
the symptoms. In so-called capillary bronchitis, the 
bubbling is due to the presence of thin mucus, and in 



MOIST BRONCHIAL RALES. 



121 



pulmonary oedema to serous transudation within the 
small bronchial ramifications. 

Fine bubbling or the so-called subcrepitant rale has 
other pathological connections, a& follows : 

1. It occurs in lobar pneumonia during the stage of 
resolution. Here it is due to the presence of mucus 
from a bronchitis limited to the affected lobe or lobes, 
and, in a measure, to liquefied pneumonic exudation. 
It is considered as denoting commencing and progress- 
ing resolution in pneumonia. Sometimes it is inter- 
mingled with rales which are more or less coarse. 

2. In circumscribed pneumonia, hemorrhagic in- 
farctus, and pulmonary apoplexy, the fine or subcrepi- 
tant rale, often associated with those which are more or 
less coarse, denotes the presence of mucus or of blood 
within the bronchial tubes. The rales are localized in 
space, or in spaces, corresponding to the situation and 
extent of the affection. 

3. During and shortly after a hsemoptysis, fine rales 
limited to a particular situation are sometimes heard, 
proceeding from blood in the small bronchial tubes, and 
indicating the situation of the hemorrhage. 

4. A purulent liquid admits of bubbling much more 
readily than mucus; hence, in cases of chronic bronchitis 
with an expectoration of pus, fine and coarse bronchial 
rSles are more frequent than in acute bronchitis. Pus, 
also, may be present within bronchial tubes of small 
size, not as a product of bronchitis, but from the evacua- 
tion of an abscess of either the pulmonary parenchyma, 
of the liver or some other adjacent part, and from per- 
foration of lung in some cases of empyema. 

5. In the different stages of phthisis, moist bronchial 
rales are usually present. The liquid in the tubes, if 



122 AUSCULTATION IN DISEASE. 

the disease be advanced, is derived, in part, from asso- 
ciated bronchitis, and, in part, from liquefied tubercu- 
lous exudation. The bubbling sounds may be more or 
less coarse or fine, and both are often intermingled. 
Early in the disease, before softening of the exudation 
has taken place, fine bubbling, or the subcrepitant rale, 
limited to the summit of the chest, is an important diag- 
nostic sign. It belongs among the accessory physical 
signs on which the diagnosis may depend. Here the 
liquid is derived from a coexisting circumscribed bron- 
chitis. 

In cases of fibroid phthisis, or cirrhosis of lung, moist 
rales, coarse and fine, are generally more or less abundant 
and diffused over the whole, or the greater part, of the 
chest on the affected side. 

In the foregoing account of the moist bronchial rales, 
the subcrepitant rale is not reckoned as a sign distinct 
from fine bubbling sounds. Inasmuch as the mechanism 
and the significance are the same, and it is not easy to 
draw a line of demarcation between the two, the dis- 
tinction is unimportant. It is sufficient to bear in mind 
that very fine bubbling sounds are called subcrepitant, 
because they are somewhat analogous to the crepitant 
rale. The points which distinguish the latter are, how- 
ever, well marked, as will appear when the characters 
of that sign are considered. The term subcrepitant 
gives rise to confusion, and there is no advantage in 
retaining it as the name of a distinct sign. Very fine 
bubbling expresses more correctly the characters of^the 
sign. The moist rales are often called mucous rales. 
This name is obviously inappropriate, since, not only 
are the sounds produced by other liquids than mucus, 



DRY BRONCHIAL RALES. 123 

but other liquids are best suited for their production, 
especially in the large and medium-sized tubes. 

The several varieties of the moist bronchial rales may 
be produced by the injection of a liquid in varying 
quantity into the bronchi of the lungs removed from the 
body of an animal of sufficient size, e. g., of the sheep 
or calf, and imitatiug respiration by means of bellows. 

The moist bronchial rales, whether coarse or fine, 
vary in pitch accordingly as the lung surrounding the 
tubes in which they are produced is, or is not, solidified. 
If the lung be solidified, the pitch is high ; if there be 
no solidification, the pitch is comparatively low. Thus, 
the pitch of the r&les is high in the second stage of 
pneumonia and in phthisis with considerable solidifica- 
tion, whereas the pitch is low in bronchitis and pul- 
monary oedema. If, therefore, the respiratory sound be 
suppressed, it is easy to determine by the pitch of these 
r&les whether the lung be solidified or not, and to judge 
measurably of the degree of solidification. Attention 
to the pitch in connection with these r&les is sometimes 
of value in diagnosis. 

Dry Bronchial Rales. 

All adventitious sounds which are not moist, produced 
within the air-tubes below the trachea, are embraced 
under the name dry bronchial rales. The sounds are 
many and varied in character. They are often musical 
notes. Frequently they are suggestive of certain familiar 
sounds, such as the chirping of birds, the cry of a young 
animal, snoring in sleep, cooing of pigeons, humming 
of the mosquito, the note of the violoncello, etc. 
They are often heard at a distance, and characterized as 



124 AUSCULTATION IN DISEASE. 

wheezing sounds. An interrupted or clicking sound is 
not uncommon. All these varieties are practically un- 
important, and it would be a needless refinement to 
consider particular varieties as distinct signs. The only 
distinction which it is desirable to make is into the 
sibilant and sonorous rales. This distinction is based on 
difference in pitch ; sibilant rales are high, and sonorous 
rales are low in pitch. As a rule, the sibilant rales are 
produced in the small and the sonorous rales in the 
larger sized bronchial tubes. The sounds may accom- 
pany either inspiration or expiration, or both. The 
sibilant and sonorous rales are often intermingled. 
There may be sibilant rales with inspiration, and 
sonorous rales with expiration, within the same situa- 
tion. Moreover, these rales are often found to vary 
from minute to minute, being at one instant sibilant 
and at another sonorous. Students are liable to con- 
found sonorous rales with bronchial breathing and some- 
times with friction-sounds. 

The physical condition represented by the dry rales is 
diminished calibre of the air-tubes at certain points, and 
especially in consequence of spasm of the bronchial mus- 
cular fibres. The latter constitutes the essential patho- 
logical condition in a paroxysm of asthma ; and in this 
affection the dry rales are always marked. Their 
diagnostic importance relates chiefly to asthma. Both 
sibilant and sonorous rales are present and diffused over 
the entire chest. Wheezing sounds with expiration are 
heard by the patient, and by others at a distance. A 
single paroxysm of asthma affords an opportunity for 
the student to observe all the varieties and fluctuations 
of these rales. Taken in connection with other signs 






VESICULAR OR CREPITANT RALE. 125 

and the symptoms, the rUles are characteristic of 
asthma. 

More or less spasm of the bronchial muscular fibres 
occurs iu certain cases of bronchitis, without being 
sufficiently great and extensive to give rise to a paroxysm 
of asthma, or even any embarrassment of respiration. 
Under these circumstances the rales are less marked and 
diffuse. An asthmatic element may be said to enter, 
more or less, into these cases. Narrowing of bronchial 
tubes by tenacious mucus which gives rise to no bubbling 
sounds, and, perhaps, unequal swelling of the mucous 
membrane, may also occasion sibilant and sonorous 
r&les. 

Dry rales at the summit of the chest are not infre- 
quent in cases of phthisis due to spasm, the presence 
of mucus, or to swelling of the mucous membrane. 
They are sometimes quite annoying to phthisical 
patients. 

Clicking sounds are suggestive of the sudden separa- 
tion of tenacious mucus from the walls of the bronchial 
tubes. These are sufficiently common in bronchitis and 
in phthisis 

Vesicular or Crepitant Rale. 

This is the only vesicular rale. It is usually con- 
sidered to be produced within the air-vesicles, but 
probably the terminal bronchial tubes or bronchioles 
participate in its production. 

It is to be distinguished from very fine bubbling 
sounds, or the so-called subcrepitant rale. The points 
of distinction are as follows : The sounds are not moist, 
l)iit dry; they are crackling, not bubbling in character. 



126 AUSCULTATION IN DISEASE. 

They may be defined to be very fine, dry, crackling 
sounds. This point of difference is very distinctive. 
There are, however, other differential points. The 
crackling sounds are equal, whereas fine bubbling 
sounds are unequal ; that is, they give the impression 
of bubbles of unequal size. The crepitating sounds are 
heard at the end of the inspiratory act, and especially 
at the end of a forced inspiration, the subcrepitant rale, 
on the other hand, being heard often with or near the 
beginning of inspiration, and, perhaps, ceasing before the 
end of the inspiratory act. Another distinctive feature 
is the abrupt development of the crepitant rale; there is 
a shower of crackles, as it were, at the end of a forced 
inspiration. Finally, the rale is never heard in expira- 
tiou. The apparent exceptions to this statement are 
instances in which the crepitant and the subcrepitant 
rale are associated. This is not very infrequent, and, 
with a practical knowledge of the characters of each, it 
is by no means difficult to appreciate the combination of 
the two signs. In fact, the combination affords an 
excellent opportunity to illustrate the distinctive char- 
acters of each ; the fine bubbling at or near the begin- 
ning of inspiration, followed by the fine crackling at the 
end of this act, and the former perhaps produced in the 
act of expiration. 

There are various modes in which the crepitant rale 
may be imitated ; for example, rubbing together a lock 
of hair near the ear, throwing fine salt upon live coals 
or into a heated vessel, igniting a train of gunpowder, 
and alternately pressing and separating the thumb and 
finger moistened with a solution of gum arabic and held 
near the ear. A perfect representation is afforded by 
squeezing a piece of an artificial preparation known as 



VESICULAR OR CREPITANT RALE. 127 

the India-rubber sponge, and observing the sound pro- 
duced by the separation of the walls of the interstices 
when the piece expands from its elasticity. This pre- 
paration exemplifies the true mechanism of the sign as 
described, first, by the late Dr. Carr, of Canaudaigua, 
N". Y., in an article published in the American Journal 
of Medical Sciences, in October, 1842. 1 Expansion of 
the lungs of the sheep or calf, after removal from the 
body, the stethoscope being applied to the lung-surface, 
gives, in certain situations, a well-marked crepitant rale. 

The crepitant rale is the diagnostic sign of pneumonia. 
It very rarely occurs in any other pathological connec- 
tion. Of all respiratory signs, this is most entitled to 
be called pathognomonic. It belongs especially to the 
first stage of acute pneumonia. It is not invariably 
present, but it occurs in the majority of cases of acute 
pneumonia. In the second stage, or the stage of solidi- 
fication, the rale generally disappears. It not infre- 
quently is reproduced in the stage of resolution, and it 
is then called the returning crepitant rale {crepitus redux). 
In the latter stage it is often found in combination with 
the subcrepitant rale. The practical value of this sign 
relates chiefly to the diagnosis of pneumonia. 

It is stated that the crepitant rale is sometimes found 
in cases of pulmonary oedema, and during or directly 
after au attack of haemoptysis. If it ever occur in 
these cases, the instances must be extremely rare. The 
statement is perhaps based on the occurrence of the sub- 
crepitaut, this being confounded with the crepitant rale. 
It occurs transiently under the following circumstances: 

1 Vide article by the author in the New York Monthly Med. Journ. 
for Feb. L869. 



128 AUSCULTATION IN DISEASE. 

A patient who has been confined for some time in bed, 
lying on the back, and much enfeebled with any disease, 
if suddenly raised to a sitting posture and auscultated, a 
crepitant rale is often found on the posterior aspect of 
the chest at the end of a forced inspiration. The rale 
disappears after a few forced inspirations. It is heard, 
not on one side only, but on both sides. The explana- 
tion is, that during the recumbent posture continued for 
some time, and the patient breathing feebly, enough of 
the air-vesicles and bronchioles become agglutinated by 
means of a little sticky transudation to give rise to 
crackling sounds in a few forced inspirations. It may 
be of use to mention that if the stethoscope be applied 
to the anterior surface of a chest much covered with 
hair, the movements of the pectoral extremity of the 
instrument in the act of inspiration may produce a sound 
identical with the crepitant rale. 

A crepitant rale at the summit of the chest, within 
a circumscribed space, is one of the accessory signs 
of phthisis. It denotes a circumscribed pneumonia 
which clinical experience shows to be generally 
secondary to phthisis; hence the diagnostic signifi- 
cance of the sign. 



Cavernous or Gurgling- Rale. 

A pulmonary cavity of considerable size, containing 
a certain quantity of liquid, and communicating freely 
with bronchial tubes, furnishes a rale which is charac- 
teristic. The character of the sound is expressed as 
fully as possible by the term gurgling. The sound is 
produced by large bubbling and the agitation of the 
liquid within the cavity. It may be compared to the 



FRICTION-SOUNDS. 



129 



sound produced by the boiling of a liquid in a flask or 
large test-tube. The sound is sometimes high pitched 
and amphoric, but generally it is low in pitch. It is 
heard with more or less intensity within a circumscribed 
space almost invariably at or near the summit of the 
chest; but, if intense, the sound is diffused, and it may 
be sometimes heard at a distance. Its diagnostic im- 
portance relates to the advanced stage of phthisis. The 
rale is heard chiefly or exclusively in the act of inspira- 
tion. It may be produced by the act of coughing some- 
times with greater intensity than by respiration. 



Pleural Rales — Friction-sounds — Metallic Tinkling — 
Splashing-. 

The signs embraced under the name pleural rales are, 
1st. Sounds produced by the rubbing together of the 
pleural surfaces, and hence called friction - sounds ; 
2d. Metallic tinkling ; and 3d. Splashing or succus- 
sion sounds. 

Friction-sounds. — Movements of the pleural surfaces 
upon each other take place in inspiration and expiration ; 
but in health these movements occasion no sound. 
Sounds are produced when the surfaces are covered 
with a recent fibrinous exudation which prevents the 
normal continuous, unobstructed movements, and when 
the surfaces are roughened with dense lymph or other 
morbid products. The sounds are generally interrupted, 
that is, two, three, or more sounds occur during the act 
of inspiration or expiration, or during both acts. The 
intensity of the sounds varies much in different cases. 
A slight grazing sound only may be heard, or, on the 
other hand, the sounds may be so loud as to be heard by 



130 AUSCULTATION IN DISEASE. 

the patient and by others at a distance. The character 
of the sounds is variable. The slight rubbing or graz- 
ing character may be imitated by placing over the ear 
the palmar surface of one hand, and moving over its 
dorsal surface slowly the pulpy portion of a finger of 
the other hand. In some instances, however, the rough 
character of the sounds is expressed by such terms as 
rasping, grating, and creaking. In these instances the 
sounds denote density of the morbid product which 
roughens the pleural surfaces. In connection with very 
rough sounds, vibration of the walls of the chest, or 
fremitus, is sometimes perceived by palpation. 

Aside from the character of the sounds as just stated, 
they are distinguished by their apparent nearness to the 
ear; they seem sometimes to be produced upon the sur- 
face of the chest. They are sometimes intensified by 
firm pressure of the stethoscope upon the chest. After 
a little practical knowledge of these sounds they can 
hardly be confounded with any other rales. 

Pleuritic friction-sounds generally denote pleurisy. 
In cases of pleurisy with effusion, slight rubbing or 
grazing is sometimes heard before much liquid accumu- 
lates within the pleuritic cavity. The physical condi- 
tions, however, after the effusion has been removed, are 
much more favorable for the production of friction- 
sounds, and they are often now rough in character. 
They may be transient, or they may continue for a 
considerable period, their duration depending on the 
arrest of the movements of the pleural surfaces by means 
of either agglutination with lymph, or adhesion from 
the growth of areolar tissue. 

Pleuritic friction-sounds occur not infrequently in 



METALLIC TINKLING. 



131 



cases of pneumonia, denoting, in this connection, coex- 
isting pleurisy. 

Slight rubbing or grazing at the summit of the chest 
is one of the accessory signs of phthisis. It denotes a 
circumscribed, dry pleurisy, which, as clinical experience 
shows, is generally secondary to phthisis, and hence the 
diagnostic significance of the sign. 

In the foregoing instances in which friction-sounds 
are stated to occur, their significance relates to pleurisy. 
In some rare instances the sounds are produced by 
miliary tubercles or carcinomatous nodules projecting 
beyond the plane of the visceral pleural surface, without 
pleuritic inflammation. 

Metallic Tinkling, — This is a vocal as well as a respi- 
ratory sign. It is also produced by acts of coughing, 
and sometimes by the act of deglutition. The name 
expresses the distinctive character of the sign. It con- 
sists in a series of tinkling sounds of a high-pitched, 
silvery, or metallic tone. The number of sounds varies 
from a single sound, to two, three, or. more sounds, 
during an act of either inspiration or expiration. This 
sign may be imitated in various ways, by means of an 
India-rubber bag of considerable size. Forcing a liquid 
into the bag with Davidson's syringe, tapping the bag 
with the finger, or shaking it, will produce tinkling 
sounds. The best mode of artificial representation of 
the sign is to connect the bag with a flexible tube, the 
latter containing a few drops of liquid, and blowing into 
the tube so as to produce bubbles at the communication 
of the tube with the bag. In this latter experiment it 
is not necessary that the bag contain any liquid. It 
occurs irregularly, that is, it is not present in every act 
of breathing, but is heard at variable intervals. It may 



132 AUSCULTATION IN DISEASE. 

sometimes be produced by forced, when it is not heard 
in tranquil, breathing. It can only be confounded with 
tinkling sounds sometimes produced within the stomach. 
The latter, however, are easily discriminated by their 
situation, and the absence of associated signs denoting 
the affections of the chest in which the sign occurs. 

Metallic tinkling is the sign of pneumothorax with 
perforation of lung. In the great majority of the cases 
in which it is found, it is diagnostic of this affection. It 
is, however, always associated with other physical signs 
corroborative of the diagnosis. 

It is a rare sign, in cases of phthisis, of a large pul- 
monary cavity, the conditions for its production being 
analogous to those in pneumo-hydrothorax, namely, a 
space of considerable size containing air, the space com- 
municating with bronchial tubes. 

Splashing, or Succussion Sounds. — This sign is pro- 
duced by succussion, which is reckoned as one of the 
different modes of physical exploration. Sounds thus 
produced are not infrequently heard at some distance; 
generally, however, succussion is practised while the ear 
is applied to the chest, so that properly enough the sign 
may be embraced among the auscultatory signs, although 
not produced by respiration. 

Splashing is pathognomonic of either pneumo-hydro- 
thorax or pneumo-pyothorax. It is especially valuable 
as a sign of these affections because it is almost invari- 
ably available. The instances are extremely few in 
which the sign is wanting when air and liquid are con- 
tained in the pleural cavity. It is obtained by jerking 
the body of the patient with a quick, somewhat forcible 
movement, the ear being very near to, or in contact 
with, the chest. 



THE VOCAL SIGNS OF DISEASE. 



133 



The sound is like that produced when a bottle par- 
tially filled with liquid is shaken. The sound is often 
high-pitched and amphoric in quality. The only liability 
to error is in confounding with this sign splashing pro- 
duced within the stomach. Attention to other signs 
will always protect against this error. 

Indeterminate Rales. — Under this head may be em- 
braced some sounds sufficiently recognizable, but indeter- 
minate as regards the rationale of their production and 
the physical conditions which they represent. They 
may be designated crumpling and crackling sounds. 
The former are probably due to pleuritic rubbing, and 
the latter to the separation of some slightly adherent 
air- vesicles or' bronchioles. Their diagnostic value re- 
lates only to the early stage of phthisis. In conjunction 
with other signs, any indeterminate rale, if limited to 
the summit of the chest, and especially to one side, has 
some weight in the diagnosis. Crumpling and crackling 
sounds, however, are not uncommon in healthy persons 
at the end of forced inspiration. The fact of their 
presence at both summits, and the absence of other 
morbid signs, are the grounds for not considering them 
as evidence of disease. They are found in health, 
especially if the binaural stethoscope be employed. 
Their diagnostic significance, thus, depends on limitation 
to the summit of the chest on one side, and association 
with other signs pointing to incipient phthisis. 

The Vocal Signs of Disease. 



The vocal signs of disease, with the exception ol 
metallic tinkling, which is a vocal as well as respiratory 
sign, may all be considered as abnormal modifications 

7 



134 AUSCULTATION IN DISEASE. 

of the normal vocal resonance and of the normal bron- 
chial whisper. The student must, therefore, be familiar 
with the distinctive characters of these two normal 
signs before he is prepared to enter upon the study of 
the abnormal modifications (vide pages 80 and 91). 
He must bear in mind the facts which have been pre- 
sented in relation to the normal vocal fremitus (vide 
page <S6). The rules given for auscultation of the voice 
are also to be observed (vide page 87). Embracing the 
abnormal modifications of the loud voice, the whisper 
and fremitus, the following are the signs to be consid- 
ered : Bronchophony ; Whispering Bronchophony ; 
iEgophony ; Increased Vocal Resonance; Increased 
Bronchial Whisper; Cavernous Whisper; Pectoriloquy; 
Amphoric Voice or Echo; Diminished and Suppressed 
Vocal Resonance; Diminished and Suppressed Vocal 
Fremitus, and Metallic Tinkling. 

Bronchophony. 

Bronchophony has the same import as bronchial or 
tubular respiration. Like the latter sign, it represents 
complete or considerable solidification of lung. Gener- 
ally the two signs are associated, hut either may be 
present without the other. 

The characters which are distinctive of bronchophony, 
as compared with the normal vocal resonance, are these: 
The vocal sound seems concentrated, in most cases near 
the ear, and the pitch is more or less raised. These 
characters are in contrast with the diffusion, distance, 
and lowness of pitch of the normal vocal resonance. 
The intensity of the sound is variable; it may be greater 
or less than the intensity of the normal resonance. A 



BRONCHOPHONY. 135 

concentrated, high-pitched sound, however feeble, is not 
less a sign of complete or considerable solidification of 
lung, that is, it is not less bronchophony, than when the 
sound is intense. 

Vocal fremitus is always to be discriminated from 
vocal resonance. The fremitus associated with broncho- 
phony may, or may not, be greater than the fremitus of 
health. Not infrequently the fremitus is less than in 
health. 

It is to be borne in mind that in some healthy per- 
sons bronchophony exists at the summit of the chest, 
especially on the right side, over the primary bronchus. 
Existing in this situation, it may not be abnormal. 

Representing complete or considerable solidification of 
lung, this sign occurs in the different affections in which 
bronchial or tubular respiration has been seen to occur 
(vide page 102), namely, lobar pneumonia, phthisis, 
chronic or fibroid pneumonia, condensation of lung from 
either pleuritic effusion, the accumulation of air in the 
pleural cavity or the pressure of a tumor, collapse of 
pulmonary lobules, coagulation of blood within the air- 
vesicles, and carcinoma and sarcoma of lung. 

For the production of bronchophony, a less degree of 
solidification is requisite than for the production of 
bronchial or tubular respiration. Hence, bronchophony 
may be associated with a broncho-vesicular, as well as 
with a purely bronchial, respiration. This is illustrated 
in the resolving stage of pneumonia. When resolution 
has progressed sufficiently for the bronchial to give place 
to (he broncho-vesicular respiration, well-marked bron- 
chophony is often found to continue, ceasing at a later 
period in the resolving stage. 

The apparent nearness to the ear of the vocal sound 



136 AUSCULTATION IN DISEASE. 

in bronchophony is wanting if a certain quantity of 
liquid intervene between the solidified lung and the 
walls of the chest at the situation auscultated. The 
voice under these conditions seems to be more or less 
distant. This difference is readily appreciated. With 
this apparent distance of the bronchophonic voice, in 
some instances is associated the modification which is 
characteristic of another sign, namely, segophony. 

Whispering Bronchophony. 

The characters of this sign correspond to those of the 
expiratory sound in the bronchial or tubular respiration 
(vide page 103). The sound is more or less intensified, 
high in pitch, aud tubular in quality. If the patient 
pronounce numerals in a forced whisper, the characters 
are generally more marked than in the expiratory sound 
iu forced breathing. The significance of this sign is the 
same as that of the bronchial or tubular respiration, and 
of bronchophony with the loud voice. 

iEgophony. 

This sign is a modification of bronchophony. As 
regards concentration aud pitch, it has the characters ot 
bronchophony, the distinctive features being apparent 
distance from the ear, and tremulousness or a bleating 
tone. From the latter the name is derived, the term 
signifying the cry of the goat. The characters which 
distinguish the sign from bronchophony are readily 
enough appreciated, and it represents a physical condi- 
tion added to solidification of lung. This physical 
condition is the presence of liquid effusion. The sign 



VOCAL RESONANCE AND FREMITUS. 137 

is rarely present in cases of large effusion. It occurs 
usually when the chest is about half filled with liquid, 
and the lung at the level of the liquid is sufficiently 
condensed to give rise to bronchophony. This condi- 
tion, under these circumstances, involves agglutination 
of lung above the portion condensed by pressure. The 
sign also sometimes occurs in cases of pleuro-pneumonia, 
the solidification in these cases being due to pneumonic 
exudation. As a sign of liquid effusion it possesses 
diagnostic value, although, owing to the fact that the 
existence of effusion is easily determined by other signs, 
it may be said to be superfluous. When the person 
examined speaks with the teeth approximated, broncho- 
phony has somewhat of the character of segophony. 

Increased Vocal Resonance and Fremitus. 



The distinctive character of this sign is an increase of 
the intensity of the resonance without notable change in 
other respects. The resonance may be more or less 
intensified, but it is distant, diffused, and comparatively 
low in pitch ; in other words, the characters distinctive 
of bronchophony are wanting. The differential points 
between bronchophony and increased resonance should 
be clearly apprehended, bearing in mind that the inten- 
sity of the sound in bronchophony may, or may not, be 
greater than the normal resonance. 

Increased vocal resonance occurs when the lung is 
solidified, the solidification not sufficient in degree to 
produce bronchophony. Lung slightly or moderately 
solidified gives rise to an increase of the intensity of the 
resonance of the voice; if the solidification becomes 
considerable or complete, bronchophony takes the place 



138 AUSCULTATION IN DISEASE. 

of the simple increase of intensity. Thus, at an early 
period in pneumonia, increased vocal resonance precedes 
bronchophony ; and in the stage of resolution the reverse 
of this takes place, namely, increased vocal resouance 
follows bronchophony, the latter ceasing when resolution 
has progressed to a certain extent. 

Contrary to what would perhaps be anticipated in the 
instances just cited, the intensity of the sound when 
bronchophony is present may be not only increased, but 
diminished below that of health ; that is, in the first 
stage of pneumonia the increased intensity may cease 
when bronchophony occurs, and return when broncho- 
phony disappears. 

Increase of the vocal resouance occurs in connection 
with pulmonary cavities. Over a cavity of considerable 
size situated near the superficies of the lung, the vocal 
resonance is sometimes extremely intense without auy 
bronchophonic characters. The latter, if present, 
denote considerable solidification either around the 
cavity, or between it and the walls of the chest. From 
the presence or the absence of bronchophonic characters 
with greatly increased intensity of resonance, the aus- 
cultator can judge whether the cavity be, or be not, in 
proximity to considerable solidification of lung. 

Irrespective of the cavernous stage of phthisis, the 
sign is of diagnostic importance in the different affec- 
tions which involve moderate or slight solidification of 
lung, namely, pneumonia early in the disease and in 
the stage of resolution, phthisis, over the compressed 
lung in pleurisy with moderate effusion, collapse of 
pulmonary lobules, hemorrhagic infarctus, and carci- 
noma and sarcoma of lung. Into the diagnosis of all 
these affections, both bronchophony and increased vocal 






INCREASED BRONCHIAL WHISPER. 139 

resonance enter; the former when solidification is con- 
siderable or complete, and the latter when it is slight or 
moderate. Increased vocal resonance is especially val- 
uable in the diagnosis of early or incipient phthisis. 
An abnormal resonance, however slight, at the summit 
of the chest on one side, is an important sign in that 
affection. In determining an abnormal resonance on 
the right side, either at the summit or elsewhere, allow- 
ance must always be made for the normally greater 
resonance on this side. 

Increased vocal resonance has the same import as 
broncho -vesicular respiration. These two sigus, how- 
ever, are not always in the same proportion ; that is, the 
characters of the latter may be marked out of propor- 
tion to the amount of the vocal resonance, and vice 
verm. 

Increased vocal fremitus generally accompanies in- 
creased vocal resonance, and it denotes a solidification 
of lung. Fremitus, however, and resonance are not 
always in equal proportion, that is, either may be in- 
creased more than the other. An increased fremitus is 
sometimes of value in the diagnosis of phthisis. The 
greater fremitus on the right side of the chest is always 
to be borne in mind, and due allowance is to be made 
for this disparity in determining that the fremitus is 
increased. 

Increased Bronchial Whisper. 

The significance of this sign is the same as (hat of 
increased vocal resonance and the broncho-vesicular 
respiration; it represents the same physical condition 
as the two latter signs, namely, solidification of lung, 



140 AUSCULTATION IN DISEASE. 

greater or less, but below the degree requisite to give 
rise to bronchophony and bronchial respiration. Its 
diagnostic application is, therefore, involved in the same 
pulmonary affections. 

The characters of the sign are those which belong to 
the expiratory sound in the broncho-vesicular respira- 
tion. They consist, therefore, of increase of intensity, 
a quality more or less tubular, and the pitch raised, 
these modifications of the normal expiratory sound 
varying in degree between the slightest appreciable 
morbid change and a close approximation to the bron- 
chophonic whisper. The modifications in degree cor- 
respond to the degree of solidification. To appreciate 
the characters of this sign, it must be studied in com- 
parison with those of the normal bronchial whisper in 
different portions of the chest. The most important of 
the diagnostic applications of the sign is in cases of 
phthisis in its early stage. In this application, the 
points of normal disparity between the two sides of the 
chest of the summit are to be borne in mind, and due 
allowance made for them (vide page 91). 

A greater intensity of the bronchial whisper at the 
right than at the left summit is not evidence of dis- 
ease ; but greater intensity at the left summit is always 
abnormal. As a rule, the pitch of the normal bron- 
chial whisper at the left is higher than that at the right 
summit; if, therefore, with a greater intensity of the 
whisper at the right summit, it be a matter of doubt 
whether it denote disease or not, when the pitch is higher 
at this summit it is to be considered as morbid. 

Cavernous Whisper. — The characters distinctive of 
the cavernous whisper are those of the expiratory sound 
in the cavernous respiration, namely, lowuess of pitch, 



INCREASED BRONCHIAL WHISPER. 



141 



and the quality blowing, that is, non-tubular. The 
intensity of the sound is variable. It is limited to a 
circumscribed space corresponding to the situation and 
size of the cavity. Not infrequently the characters of 
the sign are brought iuto contrast with those of whis- 
pering bronchophony, or increased bronchial whisper, 
these latter signs existing in close proximity, and repre- 
senting solidification of long in the immediate neigh- 
borhood of the cavity. The diagnostic application of 
this sign is chiefly to advanced phthisis. 

Pectoriloquy. — In pectoriloquy, not merely the voice, 
but the speech, is transmitted through the chest ; the 
auscnltator recognizes words uttered by the patient. 
The student, however, must not expect to be able to 
carry on a conversation with the patient by means of 
the stethoscope. Often single words only can be recog- 
nized. To make sure that these are transmitted through 
the chest, care must be taken to exclude their direct 
transmission from the patient's mouth, and the auscnl- 
tator should not know beforehand the words which are 
to be spoken. If these rules be not observed, the aus- 
cultator may err in supposing that the words are trans- 
mitted through the chest. When auscultation is prac- 
tised with one ear, the other should be closed. 

The speech with either the loud or the whispered 
voice may be transmitted, the latter, distinguished as 
whispering pectoriloquy, being much more frequent 
than the former; moreover, in determining whispering 
pectoriloquy, there is less liability to error in mistaking 
the perception of words coming directly from the mouth 
for the transmission through the chest. In the produc- 
tion of this sign, much depends on the distinctness with 
which words are articulated by the patient. Normal 
7* 



142 AUSCULTATION IN DISEASE. 

pectoriloquy at t lie anterior superior portion of the chest 
is sometimes observed. 

Pectoriloquy belongs among the cavernous signs; but 
it is by no means exclusively the sign of a cavity; the 
speech may also be transmitted by solidified lung. It 
is easy to determine in any case whether the sign denotes 
a cavity or solidified lung. If, with the transmitted 
speech, the voice have the characters of bronchophony, 
the sign represents solidification of lung; if, on the 
other hand, the characters of bronchophony be wanting, 
the sign represents a cavity. These statements apply 
equally to the loud and to the whispered voice. Of 
course, associated signs will be likely to show whether 
a cavity exists or not. It is to be added that a cavity 
and solidification of lung existing together, may con- 
jointly be concerned in the production of the sign. 

Amphoric Voice or Echo. — This sign is identical in 
character with amphoric respiration, with which it is 
usually associated (vide page 111). The amphoric into- 
nation may accompany the loud voice and the whisper; 
generally it is more appreciable or marked with the 
latter. Its significance is the same as that of amphoric 
respiration. As a rule, it represents the conditions in 
pneumothorax, namely, a large space rilled with air and 
perforation of lung. In this affection it is associated 
with other signs which suffice for a prompt and positive 
diagnosis. It is not invariably found in pneumothorax, 
and it may be present in a case at one time and wanting 
at another time, its production being dependent on the 
perforation being above the level of liquid, if the latter 
exist, and on the bronchial tubes leading to the perfora- 
tion being unobstructed. When not associated with 
other signs which are diagnostic of pneumothorax, it 



DIMINISHED VOCAL RESONANCE. 143 

denotes a phthisical cavity of considerable size. It is 
not infrequently a sign of a phthisical cavity with rigid 
walls and communicating freely with bronchial tubes. 
It has this significance whenever pneumothorax can be 
excluded ; and the associated signs in the latter affection 
are such that its exclusion is always practicable. 

The amphoric sound sometimes is observed to follow 
the oral voice ; hence the name amphoric echo. 

Diminished and Suppressed Vocal Resonance. — Dimi- 
nution and suppression of the normal vocal resonance 
occur especially when the pleural cavity contains either 
liquid or air. Whenever the lungs are not in contact 
with the walls of the chest, the vocal resonance, as a 
rule, is either notably lessened or wanting. The sign is, 
therefore, of value in diagnosis in cases of pleurisy with 
effusion, empyema, hydrothorax, and pneumothorax. 
When the pleural cavity is partially filled with liquid, 
there is diminution or suppression of the resonance 
from the level of the liquid downward ; and generally, 
just above the level of the liquid, the resonance is in- 
creased, owing to condensation of the lung. The sign 
is well illustrated by the contrast in such cases above 
and below the level of the liquid. As a rule, the 
changes of the level of the liquid with changes in posi- 
tion of the body, maybe as well demonstrated by means 
of vocal resonance as by percussion. Exceptionally, 
however, this rule is not available. 

The practical importance of diminished and sup- 
pressed vocal resonance relates chiefly to the diagnosis 
of the affections just named. In this application, how- 
ever, the associated signs must be taken into account. 
The vocal resonance may he diminished or suppressed 
when the lung is completely solidified in the second 



144 AUSCULTATION IN DISEASE. 

stage of pneumonia ; also in pulmonary oedema, and 
over the site of an intra-thoracic tumor. 

If the vocal resonance be normal, that is, neither 
increased nor diminished, we are warranted in excluding 
all the affections which have been named; the excep- 
tional instances are so rare that, practically, they may be 
disregarded. 

Diminished vocal resonance may be found over a pul- 
monary abscess before the pus is evacuated, and over a 
cavity tilled with liquid. The sign is then limited to a 
circumscribed space. Obstruction of a bronchial tube 
diminishes resonance in so far a- the column of air is a 
medium for the conduction of vocal sound. 

The normal disparity between the two sides of the 
chest is to be borne in mind with reference to diminished 
or suppressed, as well as to increased, vocal resonance; 
otherwise the relative feebleness of the resonance on the 
left side in health might be considered to be morbid. 
The normally greater resonance on the right side ren- 
ders it easier to determine a morbid diminution on this 
than on the left side. 

Diminished and Suppressed Vocal Fremitus. — This 
tactile sensation, which is appreciable in auscultation, as 
a rule, is, on the one hand, increased, and, on the other 
hand, diminished or suppressed, under the same physi- 
cal conditions which occasion corresponding modifica- 
tions of the vocal resonance. Diminished or suppressed 
vocal fremitus, therefore, has the same diagnostic sig- 
nificance as diminished or suppressed vocal resonance. 
Usually the abnormal modifications of resonance and 
fremitus go together, but either may be out of proportion 
to the other. The signs relating to fremitus thus cor- 
roborate those relating to resonance. The former may 



COUGHING OR TUSSIVE SOUNDS. 



145 



be marked when the latter admit of doubt. Diminished 
or suppressed fremitus is valuable in the diagnosis of 
pleurisy with effusion, empyema, hydrothorax, and 
pneumothorax. It is, however, to be noted that in 
exceptional instances the fremitus persists over the site 
of liquid within the chest. 

With regard to vocal fremitus, as to vocal resonance, 
it is essential to take cognizauce of the normal disparity 
between the two sides of the chest, the greater relative 
fremitus, on the right side, as a rule, being no less 
marked than the relatively greater resonance on that 
side. 

Metallic Tinkling. — This sign has the same characters 
when it accompanies either the loud or whispered voice, 
as when it is heard with respiration, and of course it 
has the same significance (vide page 95). It may be 
more marked with acts of speaking than with the respi- 
ratory acts. 



Signs obtained by Acts of Coughing or Tussive Signs. 

Acts of coughing may be made subservient to auscul- 
tation of respiratory sounds in two ways : First, by the 
removal of temporary obstruction from the accumulation 
of mucus within bronchial tubes. If the respiratory 
murmur be diminished or suppressed over a portion or 
the whole of one side of the chest, sometimes an act of 
coughing effects dislodgement of a mass of mucus from 
either a primary bronchus or one of its subdivisions, 
and the normal murmur is at once restored. The de- 
pendence of the morbid sign upon a temporary obstruc- 
tion is thus demonstrated. Second, by an act of cough- 
ing more air is expelled than by an ordinary expiration, 



146 AUSCULTATION IN DISEASE. 

and id the following inspiration the vesicles have a 
wider range of expansion, giving rise to a proportionately 
loud inspiratory sound; hence, the characters of this 
sound are more prononuced and can be better studied. 
For these two objects it is often advisable to request the 
patient to cough with a certain degree of force. 

Acts of coughing, moreover, give rise to auscultatory 
signs which have their analogues in signs obtained by 
respiration and the voice. These tussive signs are of 
less value thau the respiratory and vocal signs, and in 
niosi eases, owing to the latter being sufficient for diag- 
nosis, they may be said to be superfluous; nevertheless, 
(hey may be observed sometimes with advantage. 
When the conditions are present which are represented 
by bronchial respiration, bronchophony and the brou- 
chophonic whisper, sounds are obtained which corre- 
spond to these in their characters. The cough is then 
said to be bronchial. With the stethoscope applied over 
an empty cavity of some size, situated near the surface 
of the lung, the car receives with acts of coughing a 
concussion or shock which is sometimes so forcible as to 
be painful. This corresponds to an intense vocal reso- 
nance. Limited to a circumscribed space, it is a highly 
significant cavernous sign. It maybe present when the 
cavernous respiration is wanting. A low-pitched blow- 
ing sound corresponds to the expiratory sound in the 
cavernous respiration and the cavernous whisper. An 
amphoric intonation may be heard with acts of coughing, 
which corresponds to amphoric respiration and amphoric 
voice. This sign is sometimes more marked with cough 
than with the breathing and voice. Cavernous gurgling 
may also be obtained more distinctly with cough than 
with respiration. Finally, metallic tinkling not infre- 
quently accompanies acts of coughing. 



CHAPTER VI. 

THE PHYSICAL DIAGNOSIS OF DISEASES OE THE 
RESPIRATORY ORGANS. 

Affections of the larynx and trachea — Bronchitis seated in large bron- 
chial tubes — Bronchitis seated in small bronchial tubes., or capillary 
bronchitis — Collapse of pulmonary lobules — Lobular pneumonia — 
Asthma— Pulmonary or vesicular emphysema — Pleurisy, acute and 
cbronic — Empyema — Hyclrothorax — Pneumothorax — Pneumohydro- 
thorax — Penumo-pyothorax — Acute lobar pneumonia— Circumscribed 
pneumonia — Embolic pneumonia — Hemorrhagic infarctus— Pulmo- 
nary apoplexy — Pulmonary gangrene — Pulmonary cedema — Carci- 
noma of lung — Tumor within the chest — Acute miliary tuberculosis 
— Pulmonary phthisis — Fibroid phthisis, interstitial pneumonia, or 
cirrhosis of lung — Diaphragmatic hernia. 

In the preceding chapters the physical conditions 
incident to the morbid changes occurring in the affec- 
tions of the respiratoiy organs have been enumerated, 
and the physical signs, obtained by percussion and 
auscultation, representing these conditions, have been 
considered, severally, as regards their distinctive charac- 
ters and their significance. The object of this chapter is 
to group the physical conditions embraced in the different 
diseases of the respiratory system respectively, together 
with the representative signs on which rests the physical 
diagnosis of each of the diseases. The scope of this 
manual is limited to the physical diagnosis of these 
affections; but the faci is not to be lost sight of that in 
practical medicine physical signs arc not to be disasso- 
ciated from symptoms and pathological laws. Anexclu- 
sivc reliance on physical signs would lead to errors in 



148 PHYSICAL DIAGNOSIS. 

diagnosis, although, doubtless, errors more important 
and more frequent necessarily occur when the practi- 
tioner ignores percussion and auscultation. The signs 
furnished by percussion and auscultation only have been 
thus far considered, but in grouping these in this 
chapter, sigus obtaiued by other methods of physical 
exploration will be embraced in so far as they enter into 
the diagnosis of the different diseases of the respiratory 
system. These different diseases will be taken up sepa- 
rately with the exception of those seated in the larynx 
and trachea. With reference to physical signs, the 
laryngeal and tracheal affections may be considered 
collectively. 

Affections of the Larynx and Trachea. 

The physical sigus referable to the chest in diseases of 
the larynx and trachea, denote more or less obstruction 
to the free passage of air through these sections of the 
air-tubes. The obstruction in the different diseases 
involves different pathological conditions. Spasm of 
the glottis is one of these conditions, constituting the 
affections known as laryngismus stridulus and spas- 
modic croup, occurring also as a pathological element in 
laryngitis, and sometimes in connection with aneurism, 
or a tumor of some kind, involving the recurrent laryn- 
geal nerve. Another pathological condition is the 
opposite of this, namely, paralysis of the muscles of the 
glottis, the vocal chords remaining flaccid, and approxi- 
mating during inspiration. Other pathological condi- 
tions are, oedema of the glottis, swelling of the membrane 
at the glottis in laryngitis, together with, in the adult, 
submucous infiltration, diphtheritic exudation, cicatriza- 



AFFECTIONS OF LARYNX AND TRACHEA. 149 



tion of ulcers, morbid growths, and the presence of 
foreign bodies. 

In the affections involving the foregoing pathological 
conditions, percussion and auscultation are of use, first, 
by enabling the physician to exclude all diseases within 
the chest. The absence of signs showing the existence 
of pulmonary diseases renders it certain that the symp- 
toms denoting embarrassment of respiration are refer- 
able to the larynx or trachea. Second, by meaus of 
auscultation the amount of obstruction may be deter- 
mined more accurately than by the subjective symptoms. 
The amount of obstruction is represented by a propor- 
tionate weakening of the vesicular murmur. This is more 
reliable as regards determining a dangerous amount of 
obstruction than the sense of the want of air or the 
suffering of the patient. The degree of diminution of 
the vesicular murmur is determinable with the more 
accuracy the better the auscultator is acquainted with 
the normal intensity, that is, the intensity prior to the 
occurrence of obstruction. With this knowledge, the 
weakening of the murmur is a correct criterion of the 
amount of obstruction. In all the pathological condi- 
tions named, the respiratory murmur is more or less 
diminished in intensity on both sides of the chest; 
there are no signs obtained by percussion, nor does 
vocal resonance or fremitus offer anything distinctive. 

In cases of considerable or great obstruction during 
inspiration, inspection furnishes marked signs. The 
expansion of the chest on both sides is restricted, the 
lower part of the chest is contracted in the act of inspi- 
ration, and in this act the soft parts above the clavicles 
arc depressed. The contrast between these abnormal 



150 PHYSICAL DIAGNOSIS. 

movements aud the normal thoracic movements of the 
patient is striking and distinctive. 

An important application of* auscultation is the locali- 
zation of a foreign body which has been inhaled. If 
the vesicular murmur on both sides be more or less 
weakened, the foreign body must be situated in either 
the larynx or the trachea. If, on the other hand, the 
vesicular murmur be weakened or suppressed on one 
side, and increased on the other side, the body is lodged 
iu a primary bronchus. The importance of this appli- 
cation of auscultation before opening the trachea to 
remove a foreign body is sufficiently obvious. The 
situation of a foreign body may be changed from one 
bronchus to the other by an act of coughing, even after 
an operation has been commenced; this is, of course, at 
once determinable by auscultation. 

Bronchitis Seated in Large Bronchial Tubes. 

In bronchitis, either acute or chronic, as it is ordina- 
rily presented in practice, the inflammation is seated in 
the large bronchial tubes, in many cases probably not 
extending beyond the primary and secondary bronchi. 
The physical conditions are, more or less swelling of 
the mucous membrane, this, however, not being suffi- 
cient to occasion any notable obstruction to the free 
passage of air, and the presence, in different cases, in 
greater or less quantity, of mucus, muco-purulent 
matter, pure pus, and serum. 

The physical diagnosis involves negative rather than 
positive points; in other words, the diseases from which 
bronchitis is to be differentiated are excluded by the 
absence of their diagnostic signs. These diseases are 



BRONCHITIS IN LARGE BRONCHIAL TUBES. 151 



pneumonia, pleurisy, and phthisis. Each of these is 
characterized by the presence of signs, the absence of 
which warrants its exclusion. In bronchitis there is no 
disparity between the two sides of the chest in the reso- 
nance obtained by percussion, nor in vocal resonance, 
the bronchial whisper, and fremitus. The swelling of 
the bronchial mucous membrane may cause some dimi- 
nution of the intensity of the vesicular murmur, but as 
the affection is bilateral, and the bronchial tubes on 
each side are affected equally, both in degree and extent, 
no appreciable disparity in this respect between the two 
sides is caused by this physical condition. Weakening 
or suppression of the murmur over an area greater or 
less, may be caused by bronchial obstruction from a plug 
of mucus. This obstruction is sometimes removed by 
an act of expectoration, after which the murmur is 
found to have returned, or to have regained its normal 
intensity. 

The foregoing points, taken in connection with the 
history and symptoms, suffice for the diagnosis. Signs 
due directly to the disease represent diminished calibre 
of the tubes at certain poiuts from swelling of the mem- 
brane, adhesive mucus, and spasm of bronchial muscu- 
lar fibres. These signs are the dry bronchial rales. 
They are rarely prominent, and are oftener absent than 
present, if the bronchitis be unaccompanied by asthma; 
hence, they are of little value in the diagnosis. Other 
signs are the bubbling sounds or the moist bronchial 
rales. In acute bronchitis these are oftener absent than 
present. They occur when liquid morbid products 
within the tubes are unusually abundant, or when the 
removal of these is with difficulty effected by expectora- 
tion in consequence of muscular debility or other causes. 



152 PHYSICAL DIAGNOSIS. 

These rales are abundant and loud iu proportion as the 
liquid within the tubes is either muco-purulent, puru- 
lent, or serous in character. They are more or less 
coarse in proportion to the size of the tubes in which 
the bubbling takes place. 

The diagnostic points, negative and positive, which 
have been stated, are alike applicable to acute and 
chronic bronchitis, it being, of course, understood that 
the affection is primary, that is, not secondary to some 
other pulmonary disease. 

If the bronchitis be unaccompanied by solidification 
of lung, the moist rales which may be present are low 
in pitch. The pitch is raised if there be solidified lung 
surrounding or adjacent to the tubes in which the moist 
rales are produced. 

Bronchitis Seated in Small Bronchial Tubes — Capillary 
Bronchitis — Collapse of Pulmonary Lobules — Lobu- 
lar Pneumonia. 

Inflammation extending into the small tubes (capil- 
lary bronchitis) occasions in these the same physical 
conditions which are incident to bronchitis affecting 
tubes of large size, namely, swelling of the membrane, 
and the presence of liquid morbid products. The latter 
are not as easily removed by expectoration as when they 
are within large tubes, and, therefore, they are con- 
stantly present iu greater or less quantity. These con- 
ditions iu small tubes involve obstruction to the free 
passage of air to and from the air-vesicles; hence, the 
vast difference as regards the symptoms, the suffering, 
and the danger. The affection is bilateral, a fact greatly 
enhancing the gravity of the affection. An incidental 



CAPILLARY BRONCHITIS, 153 

physical condition is solidification, generally in dissemi- 
nated portions of king, the latter varying in number 
and size. These portions of solidified king denote 
either collapse of pulmonary lobules or broncho-pneu- 
monia, or both in conjunction. To this incidental affec- 
tion, the name "Catarrhal pneumonia" has been 
applied. Of course, any discussion of pathological 
questions suggested by these names would be here out 
of place With reference to diagnosis it is to be borne 
in mind that the solidified portions of lung in cases of 
bronchitis seated in small tubes are especially situated 
in the lower lobes. Another incidental physical condi- 
tion is temporary dilatation of the air cells, or vesicular 
emphysema, seated in the upper lobes. Both of these 
incidental conditions are bilateral, like the bronchitis 
with which they are connected. Collapse of pulmonary 
lobules, or broncho-pneumonia, or both, and emphy- 
sema occur in only a certain proportion of the cases of 
bronchitis seated in small tubes. The signs, therefore, 
admit of a division into those which relate, 1st, to the 
bronchitis, and, 2d, to these incidental affections. With 
reference to the diagnosis, the fact is to be borne in 
mind that bronchitis seated in small tubes occurs chiefly 
in children and the aged. 

The physical diagnosis of bronchitis seated in small 
tubes rests on negative facts together with a positive 
sign which is uniformly present. This sign is the fine 
moist bronchial or the so-called sub-crepitaut rale, pre- 
sent on both sides and diffused over the chest. The 
bubbling sounds are to be distinguished from the fine 
dry crackling sounds or the crepitant rale, to the char- 
acters of which the former in some measure approximate. 

The bronchitis gives rise neither to dulness on per- 



154 PHYSICAL DIAGNOSIS. 

cussion, nor to any notable change in vocal resonance, 
or fremitus. The respiratory murmur, if not obscured 
by rales, is weakened on both sides. Irrespective of 
being drowned by rales, it may be suppressed by the 
amount of bronchial obstruction. These are the nega- 
tive points in the diagnosis. In pulmonary oedema, 
line moist bronchial rales are present on both sides, but 
in this affection there is notable dulness on percussion, 
and the affection occurs in certain pathological connec- 
tions, namely, with mitral stenosis, and disease of the 
kidneys. Acute tuberculosis may present the moist 
bronchial rales with the negative points which, in con- 
nection with symptoms, characterize bronchitis seated 
in the small tubes. The differentiation is to be based 
on differences pertaining to the history and duration, 
together with the age of the patient. 

The coexistence of the incidental affections, namely, 
collapse of pulmonary lobules, or broncho-pneumonia, 
and vicarious emphysema, occasions additional signs. If 
the solidified portions of lung be considerable in either 
number or size, there will be dulness on percussion in 
circumscribed situations on the posterior aspect of the 
chest. This will be found on both sides, but perhaps 
more marked on one side. l>roncho-vesicular or the 
bronchial respiration may be present, together with the 
vocal signs of solidification, namely, cither increased 
vocal resonance, or bronchophony, and increased vocal 
fremitus. The moist rales produced within solidified 
portions of lung are high in pitch, whereas, if solidifica- 
tion do not exist, these rales are comparatively low in 
pitch. The existence of solidification at any point may 
be determined by the pitch of the rales, as well as by 
the foregoing respiratory and vocal signs. 



ASTHMA. 155 

When there are emphysematous lobules on the ante- 
rior aspect of the chest in the upper and middle regions, 
on both sides, the resonance on percussion is vesiculo- 
tympanitic, the respiratory murmur weakened or sup- 
pressed, and the rhythm altered — in short, the combina- 
tion of signs which will be stated under the head of 
emphysema. 

In the cases in which the bronchitis occasions great 
obstruction in the small tubes, and, still more, if collapse 
of lobules, or broncho-pneumonia and vicarious emphy- 
sema occur, important signs are obtained by inspection. 
The anterior portion of the chest remains expanded, and 
retraction of the lower part of the chest takes place in 
the acts of inspiration. 

Asthma. 

The pathologico- physical condition, in a paroxysm 
of asthma, is obstruction in the small bronchial tubes 
attributable to spasm of the bronchial muscular fibres. 
With this condition is associated a temporary vesicular 
emphysema, which exists often as a persistent affection 
in persons who are subject to asthma. If the emphyse- 
matous condition already exist, it is increased during 
the paroxysm of asthma. Bronchitis generally coexists, 
cither as a transient or a chronic affection. In an asth- 
matic; paroxysm, therefore, there are present the signs 
which are proper to asthma, together with those of em- 
physema, and the associated bronchitis may also occasion 
additional signs. 

The physical diagnosis of asthma, like that of bron- 
chitis seated ill small tubes, is based on negative tacts 
taken in connection with a sign which is invariably 



156 PHYSICAL DIAGNOSIS. 

present, namely, dry bronchial rales. These rales are 
more or less intense, and they are diffused over the 
entire chest. They are generally heard at a distance. 
The sibilant and sonorous varieties are mingled, and 
they are constantly changing as regards the character. 

The negative facts are the same as in capillary bron- 
chitis, namely, absence of dulness on percussion, vocal 
resonance and fremitus also being unaltered. Asthma 
and bronchitis seated in small tubes agree in the fact 
that obstruction is the important physical condition. A 
highly important differential point relates to the fre- 
quency of the respirations ; they are much increased in 
frequency in capillary bronchitis, and not in asthma. 
Pathologically they differ essentially in the fact that the 
obstruction is due in the latter affection to bronchial 
inflammation, and in the former to spasm. The two 
affections differ in the signs representing these different 
conditions, fine moist bronchial rales existing in one, 
and loud diffused dry bronchial rales existing in the 

other. 

Taking the difference as regards the positive physical 
signs in connection with the history and symptoms, the 
differentiation of the two affections may be made without 
difficulty. 

The signs which relate to the associated emphysema- 
tous condition are those which are diagnostic of this 
condition existing irrespective of asthma ; and the phy- 
sical diagnosis of emphysema will be next considered. 
Coexisting bronchitis may give rise to moist bronchial 
rales more or less coarse. These are, however, often 
wanting, and they are rarely marked during paroxysms 
of asthma. AYhen present in this pathological connec- 






VESICULAR EMPHYSEMA. 157 

tion, they are low in pitch, denoting the absence of 
solidification of luno;. 



Vesicular or Psendo-hypertrophic Emphysema. 

This affection, as a rule, is seated exclusively or 
chiefly in the upper lobes. When it is lobar, in contra- 
distinction from the emphysema existing in compara- 
tively a few disseminated or isolated portions of lung, 
increase in volume of the affected lobes is an important 
physical condition standing in relation to certain signs. 
Diminished range of expansion with acts of inspiration 
is another physical condition ; the affected lobes are in 
a permanent state of expansion approximating to that 
at the end of the inspiratory act. It follows from these 
conditions that the amount of air is in excess of the nor- 
mal proportion to the solids and liquids in the affected 
lobes. Both lungs are affected ; that is, the affection is 
bilateral. In the great majority of cases chronic bron- 
chitis coexists, and patients affected with emphysema are 
often, but by no means invariably, subject to paroxysms 
of asthma. Not infrequently an asthmatic element, 
with or without pronounced paroxysms of asthma, exists 
much of the time in connection with emphysema. The 
emphysematous condition, as a rule to which there are 
few exceptions, is greater in the upper lobe of the left 
than of the right luug. A rare condition, which is 
generally included under the name emphysema, differs 
materially from the ordinary form of this affection. 
This condition is that also known as senile atrophy of 
the lungs. The volume of the lung is not increased in 
this variety of emphysema, the proportion of air over the 
8 



158 PHYSICAL DIAGNOSIS. 

solids is, however, in excess, owing to the diminution of 
the latter from atrophy. 

The diagnostic evidence obtained by percussion is 
quite distinctive of lobar emphysema. The resonance 
over the upper and middle regions of the chest on both 
sides is vesiculo- tympanitic, that is, the intensity of the 
resonance is abnormally increased, the quality is a com- 
bination of the vesicular and tympanitic, and the pitch 
is more or less raised. Owing to the fact that the 
emphysema is greater on the left than on the right side, 
the vesiculotympanitic resonance is more marked on the 
left side. The difference in intensity between the two 
sides may lead to the error of regarding the resonance 
on the right side as dulness. The error is avoided by 
attention to the pitch and the quality pf the resonance. 
If dulness existed on the right side, the pitch of the 
sound should be higher on that side; on the other hand, 
if the difference in intensity be due to the greater amount 
of emphysema on the left side, the pitch is higher on 
that side, and the quality vesiculotympanitic. The 
attention of the student is particularly called to the 
foregoing points of distinction. Assuming that a 
vesiculotympanitic resonance exists anteriorly on both 
sides, and that it is marked on the left as contrasted with 
the right side, how is the existence of this sign on the 
right side to be determined ? The answer is, the reso- 
nance over the upper is to be compared with that over 
the lower lobe of the right lung. Percussing first over 
the upper lobe of the right lung, and second over the 
lower lobe of this lung, that is, posteriorly, below the 
scapula, or in the infra-axillary region, the vesiculo- 
tympanitic resonance over the upper lobe is rendered 



VESICULAR EMPHYSEMA. 159 

manifest. In a series of patients affected with emphy- 
sema, the uniformity of the results of percussion is very 
striking ; anteriorly, over the left side, the resonance is 
vesiculotympanitic as compared with the resonance on 
the right side, and the resonance is shown to be vesiculo- 
tympanitic on the right side anteriorly as compared with 
the resonance posteriorly below the scapula. 

As regards the abnormal modifications of the respira- 
tory murmur in emphysema, there is, first, either weak- 
ened respiratory murmur without notable change in 
pitch or quality, or suppression of the murmur. Dimin- 
ished intensity of the murmur exists over the upper 
lobes on both sides, as compared with the murmur over 
the lower lobes ; and in most cases the greater diminu- 
tion or the suppression is on the left rather than on the 
right side. Exceptions to the latter statement may be 
caused by obstruction of the bronchial tubes on the 
right, and not on the left side, by an accumulation of 
mucus, and, in rare instances, by the fact that the 
emphysema is greater on the right side. Occasionally 
there is almost suppression below with preserved respi- 
ration above of the emphysematous type, and this is 
so continuous as not to be explained by obstruction of 
tubes. /Second, modifications in rhythm are not infre- 
quent. These consist in a shortened (deferred) inspira- 
tory, and a prolonged expiratory sound. In some 
instances an inspiratory sound is wanting, and an 
expiratory sound is alone heard. The prolonged expir- 
atory sound in emphysema is always low in pitch and 
blowing or non-tubular in quality, in these respects 
differing from the prolonged expiration which denotes 
solidification of lung, the latter being high in pitch and 



160 PHYSICAL DIAGNOSIS. 

tubular in quality. These essential points of difference 
I claim to have been the first to state distinctly. 

The foregoing signs obtained by percussion and aus- 
cultation are those which are, in a positive sense, diag- 
nostic of emphysema. Associated with these are certain 
important negative facts, as follows: vocal resonance, 
vocal fremitis, and bronchial whisper are not notably 
altered. These negative points suffice to exclude other 
affections than emphysema. 

Signs obtained by inspection are quite distinctive of 
this affection. Emphysema, existing in a marked de- 
gree, causes a characteristic deformity of the chest ; the 
anterior surface is bulging, giving to the chest an abnor- 
mally rounded, bow-windowed, or barrel-shaped appear- 
ance, the lower part appearing to be contracted. This 
deformity occurs when the emphysema has been devel- 
oped in early life. The movements of the chest in 
inspiration are characteristic. In tranquil breathing 
there is but little movement of the upper and anterior 
regions, but in forced breathing the sternum and ribs 
move together as if they were one solid piece. The 
lower portion of the chest and the epigastrium are 
retracted in inspiration ; l the costal angle is diminished, 
the ribs and cartilages connected with the sternum being 
sometimes on a line ; the soft parts above the clavicle 
and sternum are often notably depressed with inspiration. 
Owing to depression of the heart downward and inward, 
the cardiac impulses are seen and felt in the epigastrium. 
Percussion and vocal resonance show the superficial 
cardiac region to be diminished or lost, the upper lobe 

i The retraction may be only apparent. Professor Janeway states 
that lie lias made measurements showing in some cases that there is no 
real retraction. 






VESICULAR EMPHYSEMA. 161 

of the left king covering this space. There may be 
more or less anterior curvature of the spine, and the 
lower portions of the scapula? may project, so that 
sometimes the plane of these bones is almost horizontal. 
These striking appearances characterize cases in which 
emphysema exists in a marked degree, and especially 
when the affection dates from early life. They are less 
marked or wanting if the emphysema be moderate in 
degree, and it have taken place in middle-aged persons 
or those advanced in years. 

In the variety of emphysema distinguished as senile, 
or senile atrophy of the kings, in which there is coales- 
cence of air-vesicles from destruction of the cell-walls 
without increased volume of the affected lobes, the 
diagnosis is to be based on the vesiculotympanitic 
resonance on percussion, weakened respiratory murmur, 
with, perhaps, the alterations in rhythm, sinking of the 
soft parts above the clavicles, and the negative points, 
exclusive of deformity of the chest, which have been 
described. 

Emphysema can hardly be confounded with any other 
affection than phthisis. The differentiation between 
these two affections is sufficiently easy if the diagnostic 
points, positive and negative, of the former, be appre- 
ciated. Phthisis occurring in a patient affected with 
emphysema makes a somewhat difficult problem in 
diagnosis; but, fortunately for the diagnostician, patients 
with emphysema very rarely become phthisical. 

Owing to the frequency with which an asthmatic 
clcincnt enters into the clinical history of emphysema, 
the dry bronchial (sibilant and sonorous) rales are often 
present, even wlieii paroxysms of asthma do not occur. 



162 THYSICAL DIAGNOSIS. 

Pleurisy, Acute and Chronic — Empyema — Hydro-thorax. 

In the first stage of acute pleurisy — that is, prior to 
the effusion of liquid — the physical conditions are, the 
presence of more or less recently exuded, soft lymph 
upon the pleural surfaces, which are now in contact, 
and restrained movements of respiration on the affected 
side in consequence of the paiu which they occasion. 
In the second stage, serous liquid accumulates within 
the pleural cavity, the quantity varyiug in different 
cases, sometimes, although rarely, filling the chest on 
the affected side. In proportion to the quantity of 
liquid the space over which the pleural surfaces are in 
contact is restricted, the movements of these surfaces 
over each other are limited, and the lung is condensed. 
In the third stage the quantity of liquid decreases, the 
space over which the pleural surfaces are iu contact 
increases, and the compressed lung is more or less 
expanded. The lymph upon the pleural surfaces be- 
comes more dense and adherent. The surfaces may 
become agglutinated by the intervening lymph. Finally, 
in convalescence, permanent adhesions result from the 
production or growth of areolar tissue. 

In subacute aud chronic pleurisy there is the same 
series of physical conditions, the points of difference 
being, as a rule, a less amount of plastic exudation, and 
a greater amount of effused liquid. The quantity of 
liquid in chrouic pleurisy is often sufficient to compress 
the lung into a small solid mass situated at the upper 
and posterior part of the chest, and to dilate the affected 
side. The heart is often removed from its normal situ- 
ation. If the pleurisy be on the left side, the heart 
may be pushed laterally beyond the right margin of 



PLEURISY, ACUTE AND CHRONIC. 163 

the sternum ; if the pleurisy be on the right side, the 
heart is pushed laterally to the left of its normal situa- 
tion. The extent of displacement is proportionate to 
the amount of pleural effusiou. 

In empyema the accumulation of pus is apt to be still 
greater than that of serous effusion in simple chronic 
pleurisy, causing, of course, greater dilatation of the 
chest, and more displacement of the heart. 

In these varieties of pleurisy the affectiou, with rare 
exceptions, is unilateral. 

In hydrothorax the conditions differ, first, as regards 
the absence of the exudation of lymph ; second, the 
affection is bilateral, the effusion of liquid taking place 
in both pleural cavities ; and, third, although the quan- 
tity of liquid may be considerably greater on one side, 
the accumulation very rarely, if ever, is sufficient to 
cause much dilatation of the chest on that side, with 
complete condensation of the lung, and notable displace- 
ment of the heart. 

The signs in the first stage of acute pleurisy are rela- 
tive feebleness of the respiratory murmur on the affected 
side, from the restrained respiratory movements on that 
side, and a rubbing friction -sound. The former is not 
distinctive of pleurisy, being present when the respira- 
tory movements on one side are restrained by pain in 
intercostal neuralgia and pleurodynia. A friction-sound 
is not always obtained. In the absence of this sound 
the physical diagnosis cannot be made with positiveness 
prior to the effusion of liquid. Assuming that the 
general and local symptoms point to an acute inflam- 
matory affection, the differential diagnosis relates to 
pleurisy and pneumonia. A pleural friction-sound may 
be present in the Latter as well as the former of these 



164 PHYSICAL DIAGNOSIS. 

two affections. The characteristic sign of pneumonia, 
the crepitant rale, being wanting, the differentiation, in 
this stage, must rest on diagnostic points pertaining to 
the symptoms. 1 

In the second stage of acute pleurisy the diagnostic 
signs are those which denote the presence of liquid 
within the pleural cavity. These signs are simple and 
distinctive. There is either dulness or flatness on per- 
cussion at the base of the chest, extending upward a 
distance proportionate to the quantity of liquid. If the 
trunk be in a vertical position — that is, the patient sit- 
ting or standing — the line of demarcation between the 
dulness or flatness and pulmonary resonance is, or 
approximates to, a horizontal line on the auterior aspect 
of the chest. This line denotes the level of the liquid, 
and is easily obtained by percussion. It is as easily 
determined by auscultating the vocal resonance, this 
either abruptly ceasing or being notably diminished at 
the level of the liquid. Having ascertained the line 
forming the upper boundary of dulness or flatness on 
the auterior aspect of the chest, the patient sitting or 
standing, if the position be changed to recumbency on 
the back, and the pulmonary resonance be found then 
to exteud more or less below this line, this fact is dem- 
onstrative proof of the presence of liquid. Proof in 
this way is obtained in a large majority of cases, the 
exceptional cases being those in which the pleural sur- 
faces are united, either by agglutination or permanent 
adhesions, above the level of the liquid.' The reso- 

■ 1 Professor Janeway states that lie has sometimes heard a crepitant 
rale at the inception of pleurisy, without coexisting pneumonia. The 
mechanism in these instances is the same as in pneumonia, 

2 The statement with regard to a horizontal line denoting the level 



PLEURISY, ACUTE AND CHRONIC 



165 



nance on percussion over the lung above the level of 
the liquid is generally vesiculotympanitic — the inten- 
sity increased, the pitch raised, the vesicular and the 
tympanitic quality combined. Sometimes there is so 
little vesicular quality in this vesiculo-tympauitic reso- 
nance, that it may seem to be purely tympanitic, and 
is suggestive of pneumothorax. Associated signs will 
always prevent this error of observation. As a rule, 
vocal resonance and fremitus are either notably lessened 
or suppressed over the portion of the chest situated 
below the level of the liquid. There are occasional ex- 
ceptions to this rule. The respiratory sound below the 
level of the liquid is suppressed. If any be heard, it is 
transmitted either from the lung above the liquid, or 
laterally, from the lung on the other side of the chest. 
Above the liquid the respiratory sound, as a rule, is 
weakened. If the amount of liquid be sufficient to 
produce much condensation of lung, the respiratory 
sound is broncho-vesicular. Sometimes, owing to the 
pleural surfaces above being adherent, a strip of lung 
at the level of the liquid is sufficiently condensed by 
compression to give a bronchial respiration. Under 
these circumstances, there will be either bronchophony 
or the modification of that sign known as segophony. 
If the lung be not sufficiently compressed for the pro- 
duction of these signs of solidification, the vocal reso- 
nance is simply more or less increased. The fremitus 



ill' the liquid does not apply to the posterior aspect of the chest. 
Observations show that posteriorly the lung extends more or less 
downward near the spinal column, and that the level of the liquid 
forms a curve which may be represented by the letter S. Vide article 
by Professor G. M. Garland, in the New York Medical Journal, number 
for November, 1879. Also treatise on " Pneumo-dynamics," by Pro- 
fessor Garland, 1878. 

8* 



166 PHYSICAL DIAGNOSIS. 

is usually increased above the liquid. Over the unaf- 
fected side the respiratory murmur is increased in in- 
tensity. 

The foregoing signs are present when the pleural 
cavity is partially filled ; a quarter, a half, or two-thirds 
of the thoracic space being occupied by liquid. The 
signs present when the cavity is completely filled will 
be presently stated in connection with chronic pleurisy. 
The signs which have been stated show not only the 
presence of liquid but its quantity. By means of these 
signs are readily ascertained the progressive increase or 
decrease in the quantity of liquid, and its disappear- 
ance. After the liquid has disappeared, often notable 
dulness on percussion remains for some time, showing 
the presence of lymph not yet absorbed. During the 
decrease of the liquid, and after its disappearance, a 
friction-murmur is often perceived. This murmur is 
now apt to be rough— a rasping, grating, or creaking 
sound. It may be loud enough to be heard by the 
patient, and by others at a distance from the chest. It 
continues sometimes for a considerable period. 

The physical diagnosis in cases of chronic pleurisy, 
when the liquid occupies a portion only of the thoracic 
space, rests, of course, on precisely the same signs as in 
cases of acute pleurisy. If, however, the chest on the 
affected side be filled and dilated, certain of the signs 
which have been stated are wanting, and others are 
added. The affected side is everywhere flat on percus- 
sion. Flatness on percussion over the whole of one 
side, the affection being chronic, denotes, as a rule, with 
rare exceptions, either chronic simple pleurisy or em- 
pyema. Respiratory sound is wanting except at the 
summit over or near the compressed lung, where it is 
bronchial. Some cases offer an important exception to 



PLEURISY, ACUTE AND CHRONIC. 



167 



this rale, namely, the bronchial respiration is diffused 
over the greater part, or even the whole, of the affected 
side. The student should bear in mind this fact; other- 
wise the diffusion of the bronchial respiration may lead 
to the suspicion that the flatness on percussion denotes 
solidification of lung and not the presence of liquid. 
Other signs, however, should always correct this error. 
Vocal resonance and fremitus are, with some exceptions, 
either suppressed or notably diminished over the whole 
of the affected side. Generally, even when the chest is 
not dilated, the intercostal depressions are lessened or 
abolished. If the walls of the chest be thinly covered 
with integument, the two sides present a marked con- 
trast in this respect. This is seen especially at the 
middle and lower regions of the chest anteriorly and 
laterally. It is especially marked at the end of the 
inspiratory act. If the affected side be dilated, this is 
apparent on inspection, and may be determined accu- 
rately by semicircular or diametric mensuration, calipers 
being required for the latter. The respiratory move- 
ments on the affected side are diminished or annulled, 
and they are increased on the healthy side, the two 
sides affording a marked contrast in this regard. If the 
pleurisy be on the left side, the impulses of the heart 
are not infrequently felt on the right of the sternum. 
If the impulses cannot be felt, auscultation shows. the 
maximum of the intensity of the heart-sounds to be 
more or less removed to the right, If the pleurisy be 
on the right side, the impulses or sounds of the heart 
denote more or less displacement laterally to the left. 
The intensity of the respiratory murmur on the unaf- 
fected side is notably increased. 

In cases of empyema the same signs are present as in 



168 PHYSICAL DIAGNOSIS. 

chronic pleurisy. The character of the liquid does not 
alter appreciably any of the signs which have been 
stated. Dilatation of the affected side of the. chest is 
more apt to occur, and to be more marked than in 
simple pleurisy. The differential diagnosis between 
these two varieties of pleurisy is to be made with posi- 
tiveness by the introduction of the needle of a hypo- 
dermic syringe having good suction force, previously 
cleaned and disinfected, and obtaining enough of the 
liquid to ascertain its character. 

When the left pleural cavity is rilled with pus, the 
movements of the heart sometimes give to the affected 
side of the chest an impulse perceived by the eye and 
touch ; hence the term, pulsating empyema. After a 
spontaneous perforation of the chest-wall, followed by 
a circumscribed purulent collection beneath the integu- 
ment, communicating with the pus within the pleural 
cavity, the tumor thus formed sometimes has a strong 
pulsation which is synchronous with the ventricular 
systole, and may give rise to the suspicion of aneurism. 

Iu cases of hydrothorax, the signs denote partial till- 
ing of the chest on both sides. The affection is bilateral. 
Generally the quantity of liquid in the two sides is not 
equal, and there is often a notable disparity in this re- 
spect. Friction sounds are never present. Variation 
of the level of the liquid with change of the position 
of the patient from the vertical to the horizontal, is 
nearly always determinable. Hydrothorax, meaning by 
this term a purely dropsical affection, is to be differenti- 
ated from double pleurisy with effusion. The history 
and symptoms, taken in connection with the signs, 
suffice for this discrimination. 



FJSTEUMOTHOKAX. 169 

Pneumothorax-— Pneumo-hydrothorax — Pneumo- 
pyothorax. 

In the extremely rare cases of pneumothorax, that is, as 
distinguished from pneumo-hydrothorax and pneumo- 
pyothorax, the physical conditions are : the presence of 
air partially or completely occupying the thoracic space, 
and condensation of lung in proportion to the space 
occupied by air. 

The diagnostic sigus are, a purely tympanitic reso- 
nance over a portion or the whole of the affected side of 
the chest : suppression of the vesicular murmur over a 
space corresponding to that in which tympanitic reso- 
nance is obtained, with notable diminution or suppres- 
sion of vocal resonance and fremitus. Over the com- 
pressed lung, if the condensation amount to complete or 
considerable solidification, there will be bronchial respi- 
ration and bronchophony ; if the solidification be neither 
complete nor considerable, there will be broncho-vesi- 
cular respiration with increased vocal resonance and 
fremitus. The accumulation of air may be sufficient 
to dilate the affected side, and to restrain or annul the 
respiratory movements on this side. The appearances 
on inspection are then precisely the same as in the cases 
of chronic pleurisy and empyema in which the affected 
side is dilated from the presence of liquid. Pneumo- 
thorax is, however, at once differentiated by the tym- 
panitic resonance on percussion. If one side of the 
chest be more or less dilated, and the resonance over the 
side be purely tympanitic, the thoracic space must be 
filled, not with liquid but with air. The intensity of 
the respiratory murmur on the healthy side is increased. 

In the great majority of cases in which the pleural 



170 PHYSICAL DIAGNOSIS. 

cavity contains air, there is also present more or less 
liquid, which may be serous or purulent. The affection 
is then known as pneumo-hydrothorax if the liquid be 
serous, and pnenmo-pyothorax if it be purulent. The 
physical conditions are the same as in pneumothorax, 
with the addition of the presence of liquid. The rela- 
tive proportions of liquid and air in different cases arc 
variable, and, also, in the same case at different periods. 

The physical diagnosis of pneumo-hydrothorax and 
of pnenmo-pyothorax, as distinguished from pneumo- 
thorax, embraces the signs of liquid, in addition to 
those of air, within the pleural cavity. If the quantity 
of liquid be large or considerable, percussion at the 
base of the chest gives flatness extending upward more 
or less, and tympanitic resonance above, the patient 
either sitting or standing. A change from the vertical 
to the horizontal position invariably causes variation of 
the upper limit of the flatness, inasmuch as the liquid 
and air change their relative situations without an 
exception. The quantity of liquid is determined ap- 
proximately by ascertaining the space over which the 
flatness on percussion extends. The line which divides 
the flatness and the tympanitic resonance does not accu- 
rately denote the level of the liquid, because tympanitic 
resonance is elicited a certain distance below this level, 
hence it is always to be assumed that the level of the 
liquid is somewhat higher than the upper boundary of 
the flatness. 

In either pneumothorax, pneumo-hydrothorax, or 
pnenmo-pyothorax, a group of auscultatory signs is 
often found which are highly diagnostic, indeed almost 
pathognomonic. These signs are amphoric respiration, 
amphoric voice or echo, and metallic tinkling. The 



ACUTE LOBAR PNEUMONIA. 171 

amphoric and the tinkling sounds may be present, either 
without the other, but they are not infrequently asso- 
ciated. Neither are present in every case, and they are 
not present in the same case at all times; their absence, 
therefore, by no means excludes the affections, and they 
are not essential to the diagnosis. When present they 
denote either air or air and liquid in the pleural cavity 
with perforation of lung or a large phthisical cavity. 
Their occurrence in the latter is comparatively rare, and 
whenever they are associated with other signs already 
stated, their diagnostic import is demonstrative. 

Pneumo - hydrothorax or pneumo-pyothorax may 
almost invariably be diagnosticated instantly by the 
presence of a succussion sound. Whenever distinct 
splashing is produced by succussion and referable to the 
chest, that is, not produced within the stomach, it is 
demonstrative of the presence of air and liquid within 
the pleural cavity. 

Acute Lobar Pneumonia. 

In the first stage of this disease there is an abnormal 
accumulation of blood within the vessels of the affected 
lobe (active congestion or hyperemia), with some exuda- 
tion within the air-vesicles and bronchioles. Generally 
there is some exuded lymph upon the pleural surface, 
this being due to circumscribed dry pleurisy. In most 
cases there is also circumscribed bronchitis, which is 
limited to the tubes within the affected lobe. In the 
second stage there is solidification due to the increase 
of exudation within the air- vesicles. The solidification, 
at first limited, extends cither rapidly or slowly, as a 
rule, over the whole lobe. Exceptionally more or less 



172 PHYSICAL DIAGNOSIS. 

liquid effusion into the pleural cavity takes place (pleuro- 
pneumonia), the pleurisy then extending beyond the 
limits of the affected lobe. In this stage the pneumonia 
may involve either another lobe of the lung primarily 
affected, or a lobe of the opposite lung, and sometimes 
the disease, by successive invasions, extends over the 
whole of one lung, together with a lobe of the opposite 
lung. The pneumonia, in these secondary invasions, is 
usually accompanied by pleurisy and bronchitis. In the 
stage of resolution the solidification of the affected lobe 
or lobes decreases, sometimes rapidly and sometimes 
slowly, until the normal condition is restored. If reso- 
lution do not take place, and the disease pass into the 
stage of purulent infiltration, the air- vesicles and bron- 
chial tubes contain a puruloid liquid in greater or less 
quantity. Exceptionally pus is collected in a cavity, or 
in cavities, constituting pulmonary abscess. 

The physical diagnosis of acute lobar pneumonia in 
the first stage must be based on the presence of the 
crepitant rale, with moderate or slight dulness on per- 
cussion over the affected lobe. There is sometimes in 
this stage a pleuritic rubbing sound over the affected 
lobe. The crepitant rale is not always present, and 
hence the affection cannot be excluded by the absence of 
this sign. When present, taken in connection with the 
symptoms, this sign is characteristic of the disease. It 
is important not to mistake for this sign fine bubbling 
or the subcrepitant rale. When the crepitant rale is 
wanting, a positive physical diagnosis must be deferred 
until more or less of the affected lobe becomes solidified, 
that is, when the disease passes into the second stage. 

The diagnosis in the second stage is to be based on 
the signs of solidification furnished by auscultation and 



ACUTE LOBAR PNEUMONIA. 173 

percussion. The auscultatory sigus are the broncho- 
vesicular, followed by the bronchial respiration ; in- 
creased vocal resonance, followed by bronchophony, and 
increased bronchial whisper, followed by whispering 
bronchophony. The signs of solidification are mauifest 
at first within a circumscribed space, situated over either 
the upper, the lower, or the middle portion of the 
affected lobe, and either rapidly or slowly the signs 
extend in most cases over the entire lobe. The crepi- 
tant rale, if it have been present in the first, generally 
disappears in the second stage. Sometimes, however, it 
is not entirely lost in this stage. The broncho- vesicular 
respiration, increased vocal resonance, and increased 
bronchial whisper are present when the solidification 
is slight or moderate; the bronchial respiration, bron- 
chophony, and bronchophonic whisper take their place 
when the solidification becomes considerable or com- 
plete. The latter signs, as a rule, speedily follow, 
inasmuch as the solidification in most cases quickly 
becomes complete or considerable. The foregoing three 
signs, denoting considerable or complete solidification, 
are usually present. Bronchial respiration, however, is 
sometimes present without bronchophony, and vice versa. 
Either, present aloue, suffices to show the existence and 
extent of the solidification. Moist bronchial or bubbling 
rales are sometimes, but rarely, heard over the affected 
lobe. 

There is notable dulness on percussion in the second 
stage. The dulness may approximate and even amount 
to flatness. If a single lobe be affected, the dulness or 
flatness extends over a space corresponding to that 
occupied by the lobe or the portion of it which is solidi- 
fied. In the antero-lateral aspects of the chest, the 



174 PHYSICAL DIAGNOSIS. 

dividing-line between the .solidified and the healthy lobe 
is readily ascertained by percussion, and this line is 
coincident with the interlobar fissure. 1 It sometimes 
happens that the upper and the lower lobe of the right 
lung arc affected, the middle lobe not becoming involved. 
The space corresponding to the middle lobe may then 
form an island of resonance surrounded by notable 
dulness on percussion. 

Whenever one lobe of a lung is affected, the resonance 
over the unaffected part of the same lung is abnormally 
increased, the pitch is raised, and the quality is vesiculo- 
tympanitic; vesiculotympanitic resonance, in other 
words, is produced. This renders more marked the 
contrast between dulness over the solidified, and reso- 
nance over the healthy, lobe. 

Over a portion of an upper lobe in the second stage, 
instead of notable dulness or flatness, there may be 
marked tympanitic resonance. This resonance proceeds 
from air within the trachea and the bronchi exterior to 
the lungs, the lung substance being completely solidi- 
fied ; it is chiefly or especially marked over the site of 
these air-tubes. In some cases the tympanitic resonance 
has either the cracked-metal or the amphoric intonation. 
These signs, per se, might suggest either pneumothorax 
or phthisical cavities; the associated respiratory and 
vocal signs, however, show only solidification of lung. 
In cases of pneumonia affecting the left lung, a tympa- 
nitic resonance is not infrequently propagated from the 
stomach more or less upward over the affected side of 

1 With referent' I" the localization of pneumonia in the upper or 
lower lobes, the situations of the interlobar fissures on the anterior, 
posterior, and lateral aspects of the ehest are to lie kept in mind, ride 
Figs. 1 and 2, pages 35 and 36. 






ACUTE LOBAR PNEUMONIA. 175 

the chest. This may be readily traced to the stomach. 
On the right side, a tympanitic resonance is sometimes 
propagated a certain distance upward from the trans- 
verse colon. 

The commencement of the stage of resolution is 
denoted by a broncho-vesicular respiration. The first 
change observed is the presence of a little vesicular 
quality in the inspiratory sound. When this is ob- 
served, the respiration is no longer bronchial, but has 
become broncho- vesicular, although the pitch is still 
high, and the expiration is prolonged, high, tubular. 
This slight change shows that air begins to enter the 
pulmonary vesicles. As resolution goes on, more and 
more of the vesicular takes the place of the tubular 
quality in the inspiratory sound, and the pitch is low- 
ered in proportion ; the expiratory sound becomes pro- 
portionately less and less prolonged, its pitch lowered, 
its quality less tubular, until, at length, the normal 
characters of the respiratory murmur are regained. 
Resolution is then complete. 

While the broncho-vesicular, respiration is under- 
going the modifications just stated, the vocal sounds 
have correspoudiug changes. Bronchophony persists 
for some time after the respiration has become broncho- 
vesicular, and then disappears, increased vocal resonance 
generally taking its place and persisting until resolution 
is completed. The bronchial whisper loses its broncho- 
phonic characters and is simply increased until its 
normal characters are regained. While the solidifica- 
tion is complete, the vocal fremitus may, or may not, 
be increased. Il is sometimes diminished. When, 
however, resolution has so far progressed thai broncho- 
phony is lost, the fremitus is usually greater than in 



176 PHYSICAL DIAGNOSIS. 

health, and so continues, but progressively lessening 
until the solidification entirely disappears. 

During the progress of resolution, the dulness on 
percussion diminishes in proportion as air enters the 
air-vesicles. If tympanitic resonance have been present 
over the upper lobe, this gives place to a vesicular 
resonance. Some dulness, however, remains after the 
completion of resolution, and persists until the exuded 
lymph on the pleural surface is absorbed. The amount 
of dulness remaining when the respiratory and vocal 
signs denote resolution, is proportionate to the quantity 
of exudation incident to the associated pleurisy. 

In this stage the crepitant rale not infrequently re- 
turns; if it have entirely disappeared during the second 
stage, and if it have persisted, it is more marked and 
diffused. It is now known as the returning crepitant 
rale, crepitus redux. More frequently the rale in this 
stage is a fine bubbling or the so-called subcrepitant. 
Both rales are not infrequently associated, and, from 
the distinctive characters of each, they are readily dis- 
tinguished. Moist rales more or less fine or coarse are 
not infrequent. The pitch of these rales remains more 
or less high until the solidifying exudation is completely 
absorbed. 

If the affection pass into the stage of purulent infil- 
tration, the respiratory sounds are feeble or suppressed, 
having, if present, more or less of the bronchial charac- 
ters. Bubbling bronchial rales, coarse and fine, are 
abundant. Weak bronchophony may persist, or the 
vocal resonance may be diminished. Fremitus may, or 
may not, be increased. Notable dulness or flatness on 
percussion remains. 

If the pneumonia result in pulmonic abscess, there 



CIRCUMSCRIBED PNEUMONIA. 177 

will be notable dulness or flatness on percussion within 
a circumscribed space, together with absence of respira- 
tory murmur, and diminished or suppressed vocal reso- 
nance. These signs warrant a probable diagnosis which 
is corroborated by the sudden expectoration of pus in a 
considerable quantity. The signs just stated may then 
be followed by those denoting a cavity, namely, caver- 
nous respiration and whisper, with intense vocal reso- 
nance. 



Circumscribed Pneumonia — Embolic Pneumonia — Hem- 
orrhagic Infarctus or Pulmonary Apoplexy. 

The form of pneumonia known as broncho-pneumo- 
nia has been considered (vide Bronchitis seated in small- 
sized tubes). Whenever circumscribed, as a rule, pneu- 
monia is secondary to some other pulmonary affection. 
Circumscribed pneumonia, giving rise to an intra- 
vesicular exudation which may disappear readily by 
resolution or absorption, is not very infrequent in cases 
of phthisis. The signs are those which represent solidi- 
fication of lung within an area more or less circum- 
scribed ; but the differentiation from the solidification 
proper to phthisis can only be made with positiveness 
after the signs have shown that the solidification has 
notably diminished or disappeared. 

In embolic pneumonia there may be dulness on per 
cussion, with feeble bronchial or broncho-vesicular 
respiration, or suppression of respiratory sound, weak 
bronchophony or increase of vocal resonance, within a 
circumscribed space, or within spaces, generally on (lie 
posterior aspect of the chest, and oftenesf on the righf 
side. These signs, taken in connection with the symp- 



178 PHYSICAL DIAGNOSIS. 

toms and pathological conditions which are consistent 
with the supposition of emboli received into the right 
side of the heart, namely, when the pulmonary symp- 
toms follow puerperal disease, ulcers, wounds, injuries, 
or venous thrombosis, render the diagnosis quite posi- 
tive. If, however, the pulmonary affection consist of 
small disseminated nodules, the foregoing signs will not 
be present. The diagnosis then must be based on the 
history and symptoms, taken in connection with the 
exclusion of other pulmonary affections by the absence 
of signs which should be present if they existed. Bub- 
bling rales, the pitch more or less raised, at different 
situations may indicate the probable sites of the nodules. 
They may be pleuritic friction-sounds. The signs may 
show, as a complication, pleurisy with effusion. 

Extravasation of blood, if it be in small spaces, gives 
rise to no definite physical signs. If, however, extravasa- 
tion extend over a considerable space, there will be dul- 
ness on percussion, with feeble or suppressed respiratory 
sound within an area corresponding to the extent of the 
extravasation. Within, and near this area, there will 
be likely to be moist bronchial rales more or less fine or 
coarse. 

Pulmonary Gangrene. 

In diffused pulmonary gangrene the physical signs 
are those of solidification extending over the greater 
part or the whole of a lobe. The diagnosis, however, 
can only be made when, in connection with these signs, 
there are present the characteristic fetor of the breath 
and expectoration. 

In circumscribed gangrene there is dulness or flatness 
on percussion within an area corresponding to the ex- 



PULMONARY (EDEMA. 179 

tent of the affection, with either suppression of respira- 
tory sound or bronchial respiration, and the vocal signs 
of solidification. Within and near this space moist 
bronchial rciles, more or less raised in pitch, are likely 
to be heard. The situation is usually on the posterior 
aspect of the chest. These signs do not suffice, for a 
positive diagnosis without the characteristic breath and 
expectoration. Cavernous signs may appear after the 
gangrenous portion of lung has sloughed away and 
been expectorated. 

Pulmonary (Edema. 

The physical condition expressed by the term pul- 
monary oedema is the presence of effused serum within 
the air- vesicles. With this condition is associated more 
or less pulmonary congestion. 

In cases of pulmonary oedema developed rapidly and 
largely in connection with renal disease, with obstruc- 
tion at the mitral orifice- of the heart, or with both these 
affections combined, giving rise to great dyspnoea, and 
liable to end speedily in death, the following are the 
diagnostic signs : Dulness on percussion on both sides 
of the chest, especially over the lower lobes, fine bub- 
bling or so-called subcrepitant rales diffused over the 
chest on both sides, together with coarser bubbling 
sounds, and the murmur of respiration notably weak 
or suppressed over the lower lobes. Inasmuch as the 
lungs are not solidified the rales are low in pitch. The 
vocal signs of solidification are, of course, wanting. 
Occasionally the crepitant rale is mingled with the fine 
bubbling sounds. 

This form of the affection is to be differentiated from 



180 PHYSICAL DIAGNOSIS. 

hydrothorax with large effusion, aud from so-called 
capillary bronchitis. Hydrothorax is always associated 
with more or less anasarca, or general dropsy, whereas, 
pulmonary oedema, even when dependent on renal dis- 
ease, may occur without dropsical effusion elsewhere. 
Moreover, the presence of liquid within the pleural cavi- 
ties, and its amount, may always be determined demon- 
stratively in cases of hydrothorax (vide Pleurisy with 
effusion and Hydrothorax). Capillary bronchitis occurs 
chiefly in children. The so-called subcrepitant rale on 
both sides of the chest is the diagnostic sign of this affec- 
tion, but it is not accompanied by dulness on percussion, 
except in so far as the bronchitis may be associated with 
lobular pneumonia or collapse of pulmonary lobules. 
The rapid development of the oedema aud its pathologi- 
cal connections, arc diagnostic points to be taken into 
account. 

Pneumonia is excluded by the fact that the affection 
is at the beginning bilateral, and by the absence of the 
signs of solidification of lung. 

Pulmonary oedema less in degree aud diffusion, has, 
of course, the same signs, not as marked and not as 
extensive, namely, dulness on percussion and fine bub- 
bling sounds or the so-called subcrepitant rales. In 
this form the affection is bilateral, and seated especially 
in the posterior and inferior portions of the lungs. 
Moreover, this form has the same pathological connec- 
tions, namely, with disease of the kidneys, and mitral 
lesions of the heart. The low pitch of the bronchial 
rales, and the absence of the respiratory and vocal signs 
of solidification, together with the fact of the affection 
being bilateral, and the coexistence of disease of the 



CAECINOMA OF LUNG. 181 

heart or kidneys, constitute the basis of a positive 
diagnosis. 

Hypostatic congestion of the lungs may occasion a 
certain amount of pulmonary oedema. The physical 
diagnosis is to be based on bilateral dulness on the pos- 
terior aspect of the chest, with low-pitched fine bubbling 
sounds, or the so-called subcrepitaut rales on both sides, 
these signs occurring under circumstances which lead to 
the supposition of this form of congestion. 

Carcinoma and Sarcoma of Lung — Tumors within the 
Chest. 

Malignant new-growths in the lungs usually assume 
the form of nodules varying in size from that of a pea 
to a hen's egg, disseminated throughout one lung or 
both lungs, in greater or less numbers. These dissemi- 
nated nodules, if of small size, have no well-marked, 
definite diagnostic signs. If limited to a lung, or if 
greater in number in one lung, they may occasion an 
appreciable dulness on percussion. They may also occa- 
sion feebleness of the respiratory murmur, and, owing 
to coexisting circumscribed bronchitis, moist bronchial 
rales may be heard at different points. These signs 
warrant a diagnosis when, as is usually the case, cancer 
is known to have existed elsewhere. With reference to 
diagnosis, it is to be borne in mind that, when cancer of 
the lung is secondary, both lungs are usually affected, and, 
when it is primary, the affection is generally unilateral. 

If there be nodules of considerable size, there will be 
well-marked dulness on percussion in different situa- 
tions, and the signs of solidification may be present, 
namely, either bronchial or broncho-vesicular respira- 



182 PHYSICAL DIAGNOSIS. 

tion, either increased vocal resonance or bronchophony, 
and increased vocal fremitus. 

In some cases of unilateral carcinoma, the greater 
part, or the whole, of a lung may be infiltrated with the 
morbid growth, increasing its volume and giving rise to 
enlargement of the affected side, diminished respiratory 
movements or immobility, flatness on percussion, with 
diminished or suppressed respiratory murmur, vocal 
resonance, and fremitus. If, as is usual, there be also 
more or less pleuritic effusion, the intercostal spaces may 
be pushed out to a level with the ribs. Here are the 
signs which denote chronic pleurisy with large effusion, 
and the differential diagnosis cannot be made with posi- 
tiveness until the fluid within the chest be withdrawn, 
and it be found that, irrespective of the bulging of the 
intercostal spaces, the physical signs remain. Explora- 
tion with a small trocar, or hollow needle, will settle the 
diagnosis when there is no pleuritic effusion, and this 
procedure is unobjectionable. 

In other cases the carcinomatous growth induces 
atrophy of the lung, diminishing its volume, aud caus- 
ing notable contraction of the affected side. The appear- 
ances on inspection are those which denote contraction 
after chronic pleurisy, and they may be present also 
in cases of fibroid phthisis or cirrhosis of lung. The 
differential diagnosis must be based chiefly on diagnostic 
points relating to the history and symptoms. 

Tumors within the chest, generally having their 
points of departure in the mediastinum, displace the 
lung in proportion to their size. They may cause con- 
siderable displacement of the heart, and produce more 
or less enlargement of the chest with diminished respira- 
tory movements. Enlargement of the subcutaneous 






ACUTE MILIARY TUBERCULOSIS. 183 

veins, indicative of venous obstruction, is often to be 
observed. Over the site of the tumor, there will be 
either dulness or flatness on percussion. Generally 
respiratory sound is wanting, vocal resonance and fre- 
mitus being either diminished or suppressed. In the 
neighborhood of the primary bronchi and over lung 
compressed by the tumor, there may be bronchial respi- 
ration, with bronchophony and increased fremitus. If 
the chest be enlarged, its enlargement is not likely to be 
as uniform as when it is dilated with liquid ; this is a 
diagnostic point, The tumor, or the tumors, may not 
be confined to one side of the chest. It is to be borne 
in mind that pleurisy with effusion may exist as a com- 
plication, and this may serve to obscure the diagnosis. 

The physical diagnosis involves differentiation from 
pericarditis with effusion and aneurisms. These affec- 
tions are to be excluded by the absence of their diagnos- 
tic signs. 

Acute Miliary Tuberculosis. 

The physical condition in this affection is the presence 
of a large number of the small bodies known as tuber- 
cles or miliary granulations, disseminated throughout 
both lungs. Bronchitis is an associated affection. 

If the tubercles be about equally distributed in the 
two lungs, there is no abnormal disparity of the reso- 
nance on percussion between the two sides of the chest, 
A comparison, also, of the two sides may afford no dis- 
parity as regards the respiratory murmur, vocal reso- 
nance, and fremitus. Moist rales, due to the associated 
bronchitis, may be present in different situations. A 
physical diagnosis, under these circumstances, cannol be 



184 PHYSICAL DIAGNOSIS. 

made with positiveness. Physical exploration, however 
is important in order to exclude other affections ; and 
the negative result, taken in connection with the symp- 
toms — pyrexia, frequently of inverse type, rapid pulse, 
accelerated breathing, etc. — renders the diagnosis ex- 
tremely probable. The differential diagnosis involves 
discrimination from capillary bronchitis, and an essential 
fever with a bronchial complication. The affection has 
been repeatedly mistaken for enteric fever. 

The tubercles may be more abundantly distributed in 
one lung. A disparity in the resonance on percussion 
may then be apparent, and, perhaps, an abnormal 
increase of vocal resonance and fremitus. These signs, 
taken in eonnection with the symptoms, establish the 
physicial diagnosis. 

Phthisis. 

With reference to physical diagnosis, cases of phthisis 
may be conveniently distributed into three groups, as 
follows : 1st. Cases in which the pulmonary affection is 
small, or eases of incipient phthisis ; 2d. Cases in which 
the affection is moderate or considerable ; and, 3d. 
Cases in which the affection has progressed to the forma- 
tion of cavities, or cases of advanced phthisis. 

In cases of incipient phthisis, the essential physical 
condition is the presence of small solidified masses, or 
nodules, the intervening vesicular structure not being 
affected. These nodules vary from the size of a pea to 
a filbert. In the vast majority of cases they are situated 
at or near the apex of either the right or the left lung. 
(Jenerallv, circumscribed capillary bronchitis coexists 
in proximity to the nodules. An intercurrent circum- 



PHTHISIS. 185 

scribed pneumonia sometimes occurs, giving rise to 
transient solidification within a limited area. Dry cir- 
cumscribed pleurisy situated over the affected portion of 
lung, generally occurs from time to time. 

In the cases of a moderate or a considerable pulmo- 
nary affection, the difference, as compared with the pre- 
ceding group of cases, consists in the presence of nodules 
of larger size, or solidification from the phthisical deposit 
extending over a space, or spaces, sufficient in size to 
give rise to well-marked physical signs. The solidifica- 
tion in these cases may be extended by the development 
of circumscribed interstitial pneumonia. The circum- 
scribed bronchitis is greater, as a rule, in degree and 
extent ; attacks of dry pleurisy may continue to occur, 
and the pleural surface becomes adherent. In these 
cases, generally, the affection, existing primarily in one 
lung, now exists in both lungs. The volume of the 
lung first affected, at the summit, is more or less 
diminished. Enlargement of the bronchial glands is 
usual, and these may be so situated as to press upon and 
diminish the calibre of one of the primary bronchi. In 
many cases, portions of lung in the neighborhood of 
solidified masses or nodules are emphysematous (vica- 
rious emphysema). 

Cases of advanced phthisis are characterized by the 
presence of a cavity, or, commonly, of cavities, varying 
in number, size, rigidity, or flaccidity of the walls, free- 
dom of communication with bronchial tubes, and the 
nearness of their situation to the superficies of the lung/ 
In cases of progressive phthisis, in addition to cavities, 
there is more or less solidification from phthisical exuda- 
tion and interstitial pneumonia. The volume of the 
lung at the summit is often notably diminished. The 



186 PHYSICAL DIAGNOSIS. 

pleural surfaces are firmly adherent. If, however, the 
disease have been retrogressive or non-progressive, 
there may be little or no solidification of lung, the 
cavity or cavities forming the only lesion. In cases of 
advanced phthisis, with very rare exceptions, both 
lungs are affected, and cavities often exist on both 
sides. 

The physical diagnosis in cases of incipient phthisis 
embraces what may be called direct and accessory signs. 
The accessory signs are those which represent incidental 
affections, namely, circumscribed bronchitis, pleurisy, 
and pneumonia. The direct signs are those representing 
the essential condition, namely, the solidified masses or 
nodules. 

An important direct sign is duluess on percussion. 
Slight duluess on percussion at the summit of the chest, 
in front or behind, is a highly important sign, taken in 
connection with symptoms, of incipient phthisis. In 
determining that a relative dulness is abnormal, the 
student must bear in mind, in the first place, the normal 
disparity between the two sides. The right side at the 
summit is relatively somewhat dull on percussion in 
healthy persons. Due allowance is to be made for this 
normal disparity. In the second place, it is to be borne 
in mind that any deformity affecting the symmetry of 
the chest will affect the relative resonance on the two 
sides; and that a deviation from symmetry attributable 
to the position of the patient will occasion a disparity on 
percussion. In the third plaee, the rules for the practice 
of percussion must be kept in mind, in order to avoid 
producing an apparent abnormal disparity by the non- 
observance of these rules (vide p. 58). Normal reso- 






PHTHISIS. 187 

nance on percussion on the two sides is a strong point 
for the exclusion of incipient phthisis. 

The direct respiratory signs in incipient phthisis are 
the broncho-vesicular respiration and weakened vesicular 
murmur. To these is to be added a localized interrupted 
or wavy inspiratory murmur as an occasional sign. Of 
course, familiarity with the characters of the broncho- 
vesicular respiration is indispensable — the combination 
of the vesicular and the tubular quality in the inspira- 
tory sound, with the pitch raised in proportion to the 
amount of tubularity, and the expiratory sound more or 
less prolonged, high, and tubular. Not infrequently 
the only appreciable morbid modification is diminished 
intensity of the murmur. When this sign is present, it 
is probable that the lack of intensity explains the 
absence of the characters of the broncho-vesicular modi- 
fications, that is, the latter sign would have been present 
were the respiratory sounds more intense. 

The direct vocal signs in incipient phthisis are, 
increased vocal resonance, increased bronchial whisper, 
and increased fremitus. The other direct signs may be 
present without an appreciable morbid increase of the 
vocal resonance or fremitus. The increased whisper 
may also be wanting, but more rarely than the two other 
vocal signs. 

In deciding on the presence or absence of each and all 
of these direct signs, it is essential to know and to cor- 
rectly judge of the disparity between the two sides of the 
chest at the summit in health. Normally the resonance 
on percussion at the summit on the right side is slightly 
dull as compared with the left side ; the inspiratory 
sound on this side has sonic tubularity in quality, and is 
somewhat raised in pitch; the expiratory sound may be 



188 PHYSICAL DIAGNOSIS. 

more or less prolonged, high, and tubular ; the vocal 
resonance on the right side is always greater, the same 
being true of fremitus ; the bronchial whisper is louder 
on the right side, and the intensity of the respiratory 
murmur is a little less on this side. Whenever it is a 
question as to a small phthisical affection at or near the 
apex of the right lung, it is a matter of experience and 
judgment to decide if the disparity in respect of these 
points be greater than normal, and it is not always easy 
to come at once to a decision. From the want of a 
proper appreciation of the several points of disparity in 
health, it is not uncommon for an erroneous diagnosis of 
phthisis to be based thereon. Appreciating the normal 
points of disparity, it is obviously easier t<» determine 
that the several direct signs of incipient phthisis are 
present at the left than at the right summit; relative 
duluess on percussion, broncho-vesicular or weakened 
respiration, increased vocal resonance, whisper, and 
fremitus, at the left summit, are, of course, always 
abnormal. 

In connection with the foregoing direct signs may be 
mentioued another sign which is often available, namely, 
an abnormal transmission of the heart-sounds. This 
sign is available only in the central portion of the infra- 
clavicular region. A slight degree of solidification of 
the summit of one lung renders the heart-sounds more 
audible in the situation just named. It is of assistance 
in determining this sign to be familiar with the following 
points of disparity which exist in health : on the right 
side the second souud of the heart is somewhat more 
audible than on the left side, and on the left side the 
first sound is a little louder than on the right side. 
Hence, if the first sound be better transmitted on the 



PHTHISIS. 189 

right than on the left side, it is abnormal ; and if the 
second sound be louder on the left side, it is abnormal. 
This sign is always to be taken in connection with other 
direct signs ; it gives greater diagnostic strength to the 
latter, but it is by no means, in itself, sufficient for the 
diagnosis. 

Corroborative evidence of incipient phthisis may be 
obtained by the -presence of accessory signs. These are : 
First, fine bubbling or the so-called snbcrepitant rale at 
the summit on one side. This sign denotes a circum- 
scribed capillary bronchitis, and this, at the summit on 
one side, is usually associated with phthisis. Second, a 
crepitant rale at the summit on one side denotes a cir- 
cumscribed pneumonia which is usually secondary to 
phthisis. Third, a pleuritic friction-sound limited to 
the summit on one side is evidence of a dry circum- 
scribed pleurisy which occurs often in the early stage of 
phthisis. Fourth, indeterminate rales, crumpling and 
crackling, are significant of phthisis if limited to the 
summit on one side. These rales, it is to be recollected, 
are sometimes found in healthy persons on forced 
breathing, especially if the binaural stethoscope be em- 
ployed. If they be normal they are found on both 
sides. The accessory signs are not sufficient for a posi- 
tive diagnosis if they exist alone ; but they are to be 
considered as corroborating the evidence derived from 
the direct signs, together with the symptoms and history. 
It is often of service in bringing out the rales to cause 
the patient to cough. 

As regards differential diagnosis, the affections with 
which incipient phthisis is likely to be confounded are 
chronic bronchitis and moderate emphysema. With 
respect to the first of these affections, namely, bronclii- 



190 PHYSICAL DIAGNOSIS. 

tis, the differentiation must depend on the presence or 
the absence of positive signs of phthisis ; in other words, 
phthisis is either diagnosticated or excluded. The 
physical signs in cases of moderate emphysema some- 
times lead to the error of supposing this aifection to be 
phthisis. Owing to the relatively greater intensity „i 
the resonance on percussion at the left summit, dulness 
is thought to exist at the right summit, and a prolonged 
expiration, with the normally greater vocal resonance 
at the right summit, are regarded as signs of phthisis. 
This error may be avoided by a careful study of the 
signs of emphysema and the normal disparity in respi- 
ration, vocal resonance, and fremitus, existing between 
the two sides of the chest. 

The physical diagnosis of a phthisical affection which 
is considerable or moderate in amount, is, in most cases, 
an easy problem. Inspection often furnishes marked 
signs. * The upper anterior portion of the chest on one 
side is depressed or flattened, and the superior costal 
movements of respiration are diminished, the chest 
elsewhere being symmetrical in both size and motions. 
There is more or less marked dulness on percussion at 
the upper part of the chest on the affected side. Some- 
times the diminished resonance is tympanitic in quality 
(tympanitic dulness) without the existence of cavities, 
the resonance being transmitted from the primary and 
secondary bronchial tubes. The respiration is either 
bronchial or broncho- vesicular approximating more or 
less to the bronchial. Occasionally, however, the respi- 
ratory sounds are too feeble for their characters to be 
appreciated. This is either bronchophony, or the vocal 
resonance is notably increased without the broncho- 



PHTHISIS. 191 

phonic characters. The whisper is either distinctly bron- 
chophonic or it is notably increased in intensity, high 
in pitch, and tubular in quality. Vocal fremitus is 
often increased. Moist bronchial rales, coarse or fine, 
are generally present. With these diagnostic signs on 
one side, the signs of a smaller amount of disease are 
generally present on the other side. 

In some cases of a moderate phthisical affection, the 
judgment may be confused by the resonance on percus- 
sion beiug increased or vesiculo-tympanitic on the 
affected side. This sign denotes the coexistence of em- 
physematous lobules (vicarious emphysema) developed 
in the progress of phthisis. The diagnosis of the latter 
affection is then to be based on the signs obtained by 
auscultation. 

The discovery of tubercle bacilli in the sputum upon 
microscopical examiuation will confirm the diagnosis in 
doubtful cases. 

Tn advanced phthisis the physical diagnosis of the 
disease is easy. The signs distinctive of this stage of 
the disease are those which denote pulmonary cavities, 
namely, tympanitic resonance on percussion within a 
circumscribed space; cracked-metal or amphoric reso- 
nance ; cavernous respiration ; cavernous whisper and 
sometimes pectoriloquy ; amphoric respiration and voice, 
and gurgling (vide Chapter V. for description of these 
signs). 

The cavernous signs are generally associated with the 
signs of solidification. In some cases, however, in 
which the disease has been non -progressive and retro- 
gressive, the cavernous signs are present without the 
signs which denote solidification of lung. 



192 PHYSICAL DIAGNOSIS. 

Fibroid Phthisis — Interstitial Pneumonia, or 
Cirrhosis of Lung. 

In this affection the physical conditions are, solidifi- 
cation from hyperplasia of the interstitial pulmonary 
tissue, dilatation of bronchial tubes (bronchiectasis), and 
diminished volume of the lung affected. The affection, 
as a rule, is either limited to or especially marked on 
one side. The whole of a lung, or only a portion of it, 
may be affected. Bronchitis always coexists. 

There is notable dulness on percussion, the dimin- 
ished resonance being sometimes tympanitic. The 
degree of resonance may vary at different examinations, 
owing to differences in the amount of morbid products 
within the bronchial tubes. The respiration is bron- 
chial, or broncho-vesicular. At times, from obstruction 
of bronchial tubes, it may be suppressed. Broncho- 
phony and increased vocal resonance are the vocal signs, 
together with the corresponding whispering signs. The 
side of the chest which is chiefly or exclusively affected 
becomes contracted either entirely or in part, resembling 
in this respect the appearances after chronic pleurisy, 
except that in the disease under consideration the chest 
wall is retracted throughout, and especially in its upper 
portion, whereas after chronic pleurisy this retraction is 
limited to or greater at the bases of the chest. 

With these signs the affection is to be differentiated 
from the ordinary form of phthisis, by reference to 
points pertaining to the symptoms and history. 

Diaphragmatic Hernia. 

The presence of more or less of the abdominal viscera 
within the thoracic cavity in consequence of a congenital 



DIAPHRAGMATIC HERNIA. 



193 



deficiency of a portion of the diaphragm, or perforation 
from accidents, or enlargement of the natural openiDgs, 
gives rise to certain anomalous signs, namely, a tympa- 
nitic resonance, variable at different times owing to 
differences as regards the quantity of gas within the 
viscera; absence of the respiratory murmur from the 
base of the chest upward, the height proportional to 
the space occupied by the abdominal organs, and the 
intestinal sounds emanating from within the chest, not 
conducted from below. 

This extremely rare affection can only be confounded 
with pneumothorax. The latter affection is to be ex- 
cluded by the absence of its diagnostic signs, irrespective 
of the tympanitic resonance on percussion. 



CHAPTER VII. 

THE PHYSICAL CONDITIONS OF THE HEART IN 
HEALTH AND DISEASE. THE HEART-SOUNDS AND 
CARDIAC MURMURS. 

Physical conditions of the heart in health : Boundaries of the pri irdia 

— Normal situation of the apex-beat— Boundaries of the deep and oi 
the superficial cardiac space — Relations of the aorta and the pulmo- 
nary artery to the walls of the chest — The heart-sounds— Characters 
distinguishing the first and the second sound— Mechanism of produc- 
tion of the heart-sounds — Auscultation of the pulmonic and the aor- 
tic second sound separately — Movements of the auricles and ventri- 
cles in relation to each other— Physical conditions of the heart in 
disease; Enlargement of the heart— Hypertrophy and dilatation- 
Abnormal impulses of the heart, and modifications of the apex-beat 
— Valvular lesions— Roughness of the pericardial surfaces— Liquid 
within ths pericardial sac — Abnormal modifications of the heart- 
sounds— Reduplication oi' heart-sounds — Cardiac murmurs— Normal 
and abnormal blood-currents within the heart, and their relations 
with the heart-sounds — Mitral direct murmur — Mitral regurgitant 
murmur— Mitral systolic non-regurgitant, or intra-ventricular mur- 
mur— Aortic direct murmur— Aortic regurgitant murmur, and in 
Aortic diastolic non-regurgitant murmur— Coexisting endocardial 
murmurs— Tricuspid direct murmur— Tricuspid regurgitant murmur 
— Pulmonic direct murmur— Pulmonic regurgitant murmur Facts 
of practical importance in relation to endocardial murmurs— Peri- 
cardial or friction murmur. 

Before entering upon the .study of the physical diag- 
nosis of the diseases of the heart, the student must be 
familiar with its anatomy and physiology. For a de- 
scription of the structure aud functions of this organ, he 
is referred to anatomical aud physiological treatises. 
The plan of this work embraces the anatomical relations 
of the heart aud the space which it occupies within the 



CONDITIONS OF HEART IN HEALTH. 195 

chest, as physical conditions of health determinable by 
normal signs, together with the heart-sounds. Having 
briefly stated these conditions of health, the morbid 
physical conditions which may be ascertained by percus- 
sion, auscultation and other methods of physical explo- 
ration, will be considered. The latter heading will 
include an account of the cardiac murmurs. 

The Physical Conditions of the Heart in Health. 

The Pnecordia — The Superficial and the Deep Cardiac 
Space. — The area on the surface of the chest correspond- 
ing to the space which the heart occupies within the 
chest, is known as the prsecordial region or the prsecor- 
dia. The upper, lower, and two lateral boundaries of 
this region must be memorized. The upper boundary 
is the third rib, the lower is a horizontal line passing 
through the fifth intercostal space; the left lateral 
boundary is at, or a little within, a vertical line passing 
through the nipple, the tinea mammillaris, and the right 
lateral boundary is represented by a vertical line situated 
about a finger's breadth to the right of the right mar- 
gin of the sternum. As the volume of the heart varies, 
within certain limits, in different healthy persons, the 
boundaries of the prsecordia are, of course, not always 
exactly the same. The foregoing statements are suffi- 
ciently accurate for practical purposes. 

The horizontal line representing the lower boundary 
of the prsecordia touches the point where the apex-beat 
of the heart is felt. The normal situation of the apex- 
beat must be recollected. In most healthy persons the 
apex-beat is felt in the fifth intercostal space, a little 
within the linea mammillaris. This is assuming the 



196 



THE HEART, 



persons to be .silling or standing; in recumbency on the 

hack the beat sometimes vises to the fourth intercostal 
space, and it is sometimes found in the fourth space in 



Fig. 9. 




_ 



the sitting or standing position of the body. The dis- 
tance from the linea mammillaris varies in different 
healthy persons ; it is sufficiently accurate to say it is a 
little within that line. (Fig. 9.) The force of the 
apex-beat varies much in different healthy persons, 
owing to other causes thau the power of the heart's 
action, such as the amount of muscular substance and 
fat in that situation, the width of the intercostal space, 
the convexity of the chest, the relation to the left lung, 



CONDITIONS OF HEAKT IN HEALTH, 



197 






etc. Allowance is to be made for these variations in 
determining the abnormal modifications of the force of 
the beat, which constitute physical signs of disease. 

Within a portion of the prnecordia the heart is un- 
covered of lung, and in the remaining portion lung 
intervenes between the heart and the walls of the chest. 
The former of these portions is called the superficial, 
and the latter is called the deep cardiac space. The deep 
cardiac space on the right side extends to the median 
line. On the left side the lung recedes at a point on the 
median line on a level with the cartilage of the fourth 
rib, and the anterior border of the upper lobe makes an 
outward curve, returning inward at or near the apex of 
the heart. This leaves the heart uncovered within an 
area which, for practical purposes, may represented by a 
right-angled triangle, the hypothenuse extending from 
the median line on a level with the costal cartilage of the 
fourth rib to the apex of the heart; the right angle 
formed by the median line and the horizontal line which 
forms the lower boundary of the prrecordia. (Figs. 9 
and 10.) 

The limits of the superficial cardiac space may be 
easily defined by percussion. It is only necessary to 
ascertain the curved line formed by the receding ante- 
rior border of the upper lobe of the left lung. A dis- 
tinct, although not great, dulncss on percussion marks 
this border of the lung. The border of the lung is as 
distinctly marked by the abrupt diminution of the vocal 
resonance, if auscultation be made with the stethoscope- 
The outer boundaries of the deep cardiac space may also 
be determined by percussion ; distinct although slight 
dulness marks the limits of the prsecordia. Defining 






198 



THE HEART, 



these follow in a certain rhythmical order, and, in health, 
thus the boundaries of the pnecordia and of the super- 
ficial cardiac space in healthy persons, on quiet breath- 
ing, full-held inspiration, and on forced expiration, 
respectively, makes a good practical exercise in percus- 
sion. 




Relations of the Aorta and Pulmonary Artery to the 
Walls of the Cited. — The base of the heart, especially 
in connection with auscultatory signs, is generally con- 
sidered to be at the second intercostal space near the 
sternum, this situation being, in reality, just above the 
base. In this situation sounds produced at the aortic 



CONDITIONS OF HEART IN HEALTH. 199 



and pulmonic orifice are best studied, either in health or 
disease. With reference to these sounds the anatomical 
relations of the aorta and the pulmonary artery to the 
right and the left second intercostal space are of impor- 
tance. If the stethoscope be applied in the second inter- 
costal space on the right side, close to the sternum, it is 
very near the aorta, and sounds produced at the aortic 
orifice are best heard in this situation. If the stetho- 
scope be applied in the second intercostal space on the 
left side, it is very near the pulmonary artery, and the 
sounds produced at the pulmouic orifice are best heard 
in this situation. Reference will be made to these two 
situations in giving an account of the heart-sounds in 
health and disease, and of adventitious sounds or mur- 
murs. (Fig. 9.) 

The Heart- sounds. — It is customary to consider the 
heart-sounds as two in number, and to distinguish them 
as the first, or systolic, and the second, or diastolic, 
sound. The characters which distinguish the heart- 
sounds in health are to be studied preparatory to the 
study of the abnormal modifications which are impor- 
tant physical signs of disease. It is essential to be able 
always to make the distinction practically between the 
so-called first, or systolic, and the second, or diastolic, 
sound in order to connect with them separately cardiac 
murmurs. The conveutioual use of the term heart- 
sounds, as distinguished from cardiac murmurs, must be 
borne in mind. The cardiac murmurs are adventitious 
sounds; they are never merely abnormal modifications 
of the heart-sounds, but they are new sounds added to 
or replacing these. 

Considering the heart-sounds as two in number, 
namely, the first, or systolic, and the second, or diastolic, 



200 THE HEART. 

(his suffices for the recognition of each. It answers all 
practical purposes to say that the sounds follow each 
other after an interval which is just appreciable, this 
interval being the short pause of the heart. After the 
recurrence of both, an interval is readily appreciable, 
called the long pause of the heart. It is not necessary 
to carry in the memory the exact relative duration 
of each of the two sounds and each of the two in- 
tervals. The fractions of a unit, in fact, do not express 
the length of the sounds and intervals as correctly as 
less definite expressions, inasmuch as the figures rep- 
resent only the mean of variations within the limits of 
health. It is sufficiently exact to say that, with the ear 
or stethoscope applied over the situation of the apex- 
beat, the systolic sound is longer than the diastolic, 
louder, lower iu pitch, and has a quality which may be 
called booming. Per contra, the diastolic sound is 
shorter, weaker, higher in pitch, and has a quality 
which may be called valvular or clicking. Aside from 
the relative length, the other characters are more or less 
marked in different healthy persons. 

These distinctive characters of the systolic and dia- 
stolic heart-sounds are apparent when the ear or stetho- 
scope is applied over the apex. At the base of the 
heart, that is, in the second intercostal space near the 
sternum, the characters of the systolic sound are not the 
same as over the apex. The diastolic sound in this 
situation is louder than the systolic. The latter is said 
to be accentuated at the base, the systolic sound being 
accentuated at the apex. Moreover, the systolic sound 
at the base may not be longer than the diastolic ; it loses 
more or less of its booming quality, the pitch remaining 
lower than that of the diastolic sound. Removing the 
car or the stethoscope a certain distance from the apex 



CONDITIONS OF HEART IN HEALTH. 201 

in any direction, occasions similar changes in the char- 
acters of the systolic sound. The interposition of several 
thicknesses of a napkin has the same effect. 

From the differential characters over the apex, and 
the rhythm alone in other situations, there is no diffi- 
culty in distinguishing the systolic from the diastolic 
sound in health. In cases of disease, however, owing 
to disturbance of the rhythm, modifications of the char- 
acters of the systolic sound, and the absence sometimes 
of one of the sounds, other means of recognition must 
be resorted to. If the apex-beat can be felt, this offers 
a ready way for recognizing the systolic sound — the 
sound which is synchronous with the apex-beat is, of 
course, the systolic sound. This mode is not always 
available, inasmuch as the apex-beat cannot always be 
felt. Another mode is always available, namely, feeling 
the carotid pulse. The carotid pulse is synchronous 
with the systolic sound, whereas there is a slight interval 
between this sound aud the radial pulse. 

The student is aided in comprehending certain physi- 
cal signs by taking into view the mechanism of the 
production of the heart- sounds. The diastolic sound is 
produced by the sudden forcible closure of the aortic 
and the pulmonic valves. This closure is caused by a 
retrograde movement of the columns of blood in the 
aorta and pulmonary artery, directly the ventricular 
systole is ended. The retrograde movement is due to 
the recoil of the coats of the arteries which have been 
dilated by the column of blood moving onward during 
the ventricular systole. This recoil causes regurgitation 
into the ventricle when either the aortic or the pulmonic 
valve is rendered incompetent by lesions. The mechan- 
ism of the systolic sound is less simple. This sound is 



202 THE HEART. 

in part due to the forcible tension of the auriculo-ven- 
tricular valves, caused by the systole of the ventricles. 
In this way is produced a valvular element of the sys- 
tolic sound. That the impulsion of the heart agaiust 
the walls of the chest furnishes another element, seems 
demonstrable. 1 To this element of impulsion the sys- 
tolic sound is indebted for its greater intensity, as com- 
pared with the diastolic sound, its length, and its boom- 
ing quality. This is shown by the fact, already stated, 
that when auscultation is made at a certain distance 
from the apex, these characters are eliminated, and by 
the fact that diseases which diminish or arrest the impul- 
sion movements of the heart produce the same modifica- 
tions. The valvular element of the systolic sound is 
weaker than the diastolic sound, a fact which at first 
occasions surprise when the difference in size between 
the aortic and pulmonic and the auriculo-ventricular 
valves is considered. The explanation of this apparent 
incongruity is as follows : the aortic and pulmonic seg- 
ments at the end of the ventricular systole are in contact 
with the arterial walls, and are expanded when the recoil 
of the latter follows. On the other hand, when the 
ventricular systole takes place in health, the auriculo- 
ventricular valves are not in contact with the walls of 
the ventricles, but they are floated out, and the orifices 

1 The part played by the impact of the heart against the chest-wall 
in the production of the first sound is at the present time regarded as 
unimportant. The closure of the auriculo-ventricular valves, the sud- 
den vibratile tension of the great vessels and ventricular walls, and, to 
an unimportant extent, the sonorous vibrations proceeding from a large 
mass of muscle-substance in the act of contracting, constitute the main, 
if not the only factors. The author's argument is equally valid as sup- 
porting this view. The subject has excited much controversy and can- 
not now be regarded as settled. I have preferred, therefore, to allow the 
text relating to this matter to stand. — Emtor of Fifth Edition. 



CONDITIONS OF HEART IN HEALTH. 203 

are nearly or quite closed ; the movement of the blood, 
therefore, in the systole only renders these valves tense. 
The diastolic sound, in other words, is due to the expan- 
sion of the sigmoid valves of the aorta and pulmonary 
artery, whereas, the valvular element of the systolic 
sound is due to merely tension of the auriculo- ventricular 
valves. The foregoing poiuts relating to the heart-sounds 
were contained in my prize essay " On the Clinical Study 
of the Heart-sounds in Health and Disease," published 
in the Transactions of the American Medical Association, 
in 1852. 1 

With reference to importaut bearings on auscultation 
in disease, the diastolic or second sound is to be studied 
as produced at the aortic and the pulmonic orifice sepa- 
rately. Recalling the anatomical relations of the aorta 
and the pulmonary artery to the walls of the chest, if 
the stethoscope be applied in the second intercostal 
space on the right side close to the sternum, the charac- 
ters of the diastolic sound are derived chiefly from the 
aortic valve, and if the stethoscope be applied in the 
second intercostal space on the left side close to the 
sternum, the characters of the diastolic sound are 
derived chiefly from the pulmonic valve. The correct- 
ness of this statement is proved by differences in the 
characters of the sound on two sides in health, and by 
the modifications in cases of disease. These morbid 
modifications will enter into the physical diagnosis of 
cardiac affections. In health the aortic diastolic sound 
is somewhat louder, higher in pitch, and the valvular 
quality more marked than the pulmonic diastolic sound. 

1 Vide, also, " Treatise on Disease of the Heart," firsl edition, I860; 
- h.I edition, 1870. 



204 THE HEART. 

The student should verify these points of difference by 
the study of the diastolic sound in the two situations 
just named. In order for the comparison to be a fair 
one in health, and available in the diagnosis of disease, 
the normal anatomical relations to the walls of the 
chest, of the aorta, and pulmonary artery must be pre- 
served. These relations are affected by changes in the 
symmetry of the chest, and sometimes by enlargement 
of the heart. The luugs must also be free from disease ; 
otherwise, the transmission of the sounds will be ab- 
normal. 

In the account of the mechanism of the production 
of the heart-sounds (vide page 201), it was stated that 
the first or systolic sound consists of a valvular element 
and an element of impulsion. This valvular element 
is a two-fold sound, that is, it is a combination of a 
sound produced by the mitral and a sound produced by 
the tricuspid valve. These two valvular synchronous 
sounds may be studied separately in health, and their 
abnormal modifications constitute important diagnostic 
signs in cases of disease. This fact was pointed out in 
my prize essay "On the Clinical Study of the Heart- 
sounds," in 1852. 

The two valvular sounds may be designated the 
mitral and the tricuspid systolic sound. Adding to 
these two sounds the sound of impulsion produced by 
the movements of the apex, with the ventricular systole, 
there are three distinct sounds. The diastolic or second 
sound of the heart, as has been seen, is resolvable into 
two distinct sounds. Hence, the number of distinct 
heart-sounds is, in reality, five, two of which are dia- 
stolic and three systolic, namely, the mitral valvular 
the tricuspid valvular, the sound of impulsion, the 



CONDITIONS OF HEART IN HEALTH. 205 

aortic and the pulmonic. Each of these five sounds 
may be studied separately in health aud disease. The 
abnormal modifications of each furnish important in- 
formation in diagnosis. 

In health, the sound of impulsion is heard over the 
situation of the apex-beat of the heart. The mitral 
valvular sound is studied by listening with the stetho- 
scope applied to the left of the apex at a distance suffi- 
cient to eliminate the sound of impulsion. 

The tricuspid valvular sound is heard at a little dis- 
tance to the right of the inferior border of the heart. 

In the pages which follow I shall sometimes refer 
to the systolic and the diastolic sound in the singular 
number, it being understood that the systolic sound em- 
braces three, and the diastolic two, components ; and at 
other times I shall refer to the sounds separately which 
are combined in the two sounds. 1 

The order of the succession of the movements of the 
auricles and of the ventricles is to be kept in mind with 
reference to the comprehension of certain physical signs 
of disease. Points of especial importance are the con- 
traction of the auricles in the latter part of the long- 
pause of the heart, preceding the ventricular systole, 
and the twisting of the heart from left to right in the 
systole, this movement being reversed in the diastole. 
In these systolic aud diastolic twisting movements, the 
pericardial surfaces move upon each other, but in health 
noiselessly owing to their smoothness and moisture. 
The movements occasion an auscultatory sign, namely, 
a friction murmur, when the surfaces are roughened by 
the presence of lymph. Other points are the size of the 

1 Vide paper on the clinical study of the heart-sounds, by the 
Author, in the Journal of the American Medical Association, 1884. 
10 



206 THE HEART. 

pericardial sac, that is, its capability of holding when 
filled, but not dilated, from fifteen to twenty ounces of 
liquid, and its attachment, not to the base of the heart, 
but to the vessels above the base. 



Physical Conditions of the Heart in Disease. 

The physical conditions of the heart in disease, which 
are determinable by physical exploration, are, 1st, 
enlargement of the heart ; 2d, abnormal impulses aud 
modifications of the apex-beat ; 3d, valvular lesions ; 
4th, roughness of the pericardial surfaces; and, 5th, 
liquid within the pericardial sac. Having considered 
these conditions, an account of abnormal modifications 
of the heart-sounds and cardiac murmurs will conclude 
this chapter. 

Enlargement of the Heart. — Enlargement of the heart 
may be slight, moderate, great, or very great, these 
terms expressing different degrees of enlargement with 
sufficient precision for clinical purposes. In cases ol 
very great enlargement, the space within the chest which 
the heart occupies may be from four to five times larger 
than in health. The situation of the base of the heart 
is but little, or not at all, changed in cases of enlarge- 
ment; the increased space which the heart occupies is 
therefore downward. The increased space extends much 
more to the left than to the right; the left border of the 
heart, in proportion to the enlargement, is carried 
beyond the mammary line on the left side, whereas, the 
right border is carried comparatively but little beyond 
the normal right lateral boundary of the prsecordia even 
when the enlargement is very great. The superficial 
cardiac space is enlarged in proportion to the enlarge- 



CONDITIONS OF HEART IN DISEASE. 207 



merit of the heart; the organ pushes to the left the 
receding anterior border of the upper lobe of the left 
lung, and is proportionately in contact, uncovered of 
lung, with the walls of the chest. The apex of the 
heart is lowered in proportion to the enlargement, and 
it is carried more or less to the left of its normal situa- 
tion. It may be lowered to the sixth, seventh, eighth, 
or ninth intercostal space. The enlargement of the 
heart is rarely equal in all its parts. The ventricular 
enlargement may be entirely or chiefly of either the 
right or the left ventricle. Enlargement of the right 
ventricle tends to carry the right side of the heart more 
to the right than when the left ventricle is enlarged. 
The situation of the apex is also affected by the parts of 
the heart in which the enlargement predominates. The 
apex is carried further to the left of its normal situa- 
tion, other things being equal, when the enlargement 
predominates on the right side of the heart ; and it is 
lowered without being carried far to the left when the 
enlargement of the left ventricle predominates. The 
apex of the organ in cases of considerable or of great 
enlargement becomes changed in form ; it is rounded or 
blunted. This change is most marked when enlargement 
of the right ventricle predominates. All these points 
are of importance with reference to the comprehension 
of the physical signs of enlargement of the heart. 

Enlargement of the heart may be entirely due either 
to hypertrophy or to dilatation (simple hypertrophy and 
simple dilatation). If, however, the enlargement be 
sufficient to occasion notable disturbance of the circula- 
tion, both these forms of enlargement are combined, but, 
as a rule, one or the other form predominating ; so that, 
of the cases of diseases of the heart which come under 



208 THE HEART. 

medical treatment, the majority are cases of either 
enlargement with predominant hypertrophy or enlarge- 
ment with predominant dilatation. 

These widely different physical conditions are con- 
cerned especially in the abnormal impulses and modifi- 
cations of the apex-beat, as well as, also, the heart- 
sounds. 

Abnormal Impulses of the Heart, and Modifications 
of the Apex-beat. — The abnormal situation of the apex 
of the heart when enlarged has been stated. Generally 
the situation is determinable by the apex-beat. It has 
been seen that in health the beat is sometimes not appre- 
ciable by the touch, owing to the thickness of the soft 
parts, and the conformation of the thorax, and, for these 
reasons, the force of the beat varies much in different 
healthy persons. Exclusive of normal variations, the 
beat is generally strong and prolonged in proportion as 
the heart is enlarged by hypertrophy. There are excep- 
tions to this statement, which are to be explained by the 
altered form of the apex ; when it loses its pointed form 
it does not so readily come in contact with the walls of 
the chest in an intercostal space, and, hence, the beat 
may be weak although the ventricular systole be abnor- 
mally strong. On the other hand, the apex-beat is 
weakened by dilatation, and it may be wanting as a 
result of diminished strength of the systole of the ven- 
tricles. The apex-beat is also abnormally weak in fatty 
degeneration and softening of the heart, as well as in 
functional debility of the organ incident to other diseases 
than those of the heart. 

[f there be considerable or great enlargement, the 
heart being in contact with the walls of the chest over a 
larger area than in health, impulses other than the apex- 



CONDITIONS OF HEART IN DISEASE. 209 

beat are generally apparent to the eye and touch. Not 
infrequently impulses are appreciable in each intercostal 
space between the situation of the apex and the base of 
the heart. These abnormal impulses are felt to be 
strong in proportion as the enlargement is due to hyper- 
trophy, and weak in proportion as dilatation predomi- 
nates. Enlargement of the right ventricle causes an 
impulse in the epigastrium which is strong or weak in 
proportion as hypertrophy or dilatation predominates. 
Cardiac impulses are felt and seen in abnormal situa- 
tions when the heart is removed from its normal 
situation by the pressure of an aneurism, or other tumor, 
by pleuritic effusion, hydroperitoneum, etc. The error 
of mistaking for a cardiac impulse the pulsation of an 
aueurismal tumor is to be avoided. Another error is to 
be avoided, namely, mistaking abnormal impulses due 
to the heart being uncovered of lung, from shrinking of 
the latter in certain pulmonary affections, for impulses 
denoting enlargement of the heart. In cases of enlarge- 
ment by hypertrophy, a heaving movement of the whole 
prpecordia is sometimes felt when the hand is applied to 
the chest. A violent shock is sometimes felt by the 
hand applied to the praecordia, but without the impres- 
sion of increased muscular power, in cases of purely 
functional disorders of the heart. 

Valvular Lesions. — The lesions affecting the valves 
of the heart are of a varied character, for an account 
of which the student is referred to treatises on cardiac 
diseases, or on pathological anatomy. It suffices here 
to consider that, with reference to physical signs and 
pathological effects, they may be distributed into three 
groups, as follows : 1st, lesions which diminish more or 
less the size of the orifices, or obstructive lesions; 2d, 



210 THE HEART. 

lesions which render the valves more or less incompe- 
tent and permit regurgitation, or regurgitative lesions; 
and, 3d, lesions which roughen the surfaces over which 
the blood moves without occasioning either obstruction 
or regurgitation. The latter may be distinguished as 
innocuous lesions, giving rise to no pathological effects 
although represented by cardiac murmurs. 

It is to be borne in mind that in the great majority 
of cases valvular lesions are seated in the left side of 
the heart ; that is, they are either mitral or aortic. Tri- 
cuspid and pulmonic lesions are comparatively rare, 
and they are generally congenital. Not infrequently 
mitral aud aortic lesions coexist, and there may be co- 
existing lesions at all the orifices of the heart. 

Valvular lesions are represented by cardiac murmurs. 
By means of the murmurs the existence of lesions is 
known, their situation at the different orifices may be 
ascertained, and, generally, it is practicable to determine 
whether they occasion obstruction or regurgitation, or 
both. These several points of inquiry will be consid- 
ered presently under the heading Cardiac Murmurs, 
and in connection with the lesions of the different valves 
respectively, in the next chapter. 

Roughness of the Pericardial Surfaces. — In place of 
the smoothness of the pericardial surfaces in health, 
which permits their movements upon each other noise- 
lessly, the presence of the inflammatory product lymph, 
and, in some rare instances, morbid growths, occasion 
an adventitious sound or murmurs, which will be 
noticed in connection with other murmurs, aud as enter- 
ing into the physical diagnosis of pericarditis. 

Liquid within the Pericardial Sac. — More or less 
liquid transudes into the pericardial sac in cases of 



CONDITIONS OF HEART IN DISEASE. 211 

general dropsy or anasarca, but rarely in very large 
quantity. Liquid effusion occurs in acute pericarditis, 
and in this affection the sac may become filled with 
liquid. In some cases of chronic pericarditis the sac 
is greatly dilated by liquid, the quantity amounting to 
four pounds, or even more. 

When the pericardial sac is filled with liquid, without 
being dilated, it forms a pyriform tumor within the 
chest, the base of which is at the sixth or seventh inter- 
costal space ; the apex rises nearly to the sternal notch ; 
the left lateral border is considerably beyond the nipple, 
and the right lateral border is more or less beyond the 
right margin of the prsecordia. The anterior portion 
of the filled pericardium is mostly uncovered of lung 
and in contact with the walls of the chest. Within 
this area there is either notable dulness or flatness on 
percussion, together with absence of respiratory murmur 
and of vocal resonance. By means of these signs, the 
boundaries of the pyriform tumor may be readily de- 
lineated on the surface of the chest. The difference in 
form and situation of the area of dulness or flatness on 
percussion in cases of large pericardial effusion, from 
the area in cases of enlargement of the heart (vide page 
206), is to be noted and borne in mind with reference 
to the differential diagnosis. 

When the pericardial sac is partially filled with 
liquid, the same signs are present, but within an area 
of less extent, and the configuration of the pyriform 
tumor is wanting. 

In cases of chronic pericarditis with a large accumu- 
lation of liquid, the pericardial sac is dilated so that its 
lateral boundaries may extend nearly to the axillary 
and infra-axillary regions. Under these circumstances, 



212 THE HEART. 

flatness on percussion, absence of respiratory murmur 
and of vocal resonance, are present over the greater part 
of the anterior aspect of the chest. 

Abnormal Modifications of the Heart-sounds. 

In order to appreciate the abnormal modifications of 
the heart-sounds, their normal characters are to be kept 
in mind (vide page 200), and the student must be prac- 
tically familiar with them. The modifications relate to 
the three components of the systolic sound, and to the 
two components of the diastolic sound, collectively and 
separately. 

The sound of impulsion, as heard over the apex, is 
intensified in hypertrophy of the heart. This sound is 
not only notably loud, but prolonged, and its booming 
quality is marked. It sometimes has a ringing tone, 
called tinnitus. The systolic valvular sounds, namely, 
the mitral and the tricuspid, are also more or less in- 
creased in intensity. The increased intensity of either 
the mitral or the tricuspid valvular sound, separately 
denotes that the hypertrophy is seated especially in 
either the left or the right ventricle. 

In some cases of violent palpitation the systolic 
sounds are notably intensified, the souud of impulsion 
being comparatively weak. I suppose the explanation 
to be as follows : the ventricles contract with a kind of 
spasmodic action upon a small quantity of blood ; and, 
under these circumstances, the auriculo -ventricular 
valves, not being floated out as they are when the ven- 
tricles are well filled, expand with force in the ventricu- 
lar systole, instead of being merely made tense as in 
health. Hence, the valvular sounds are intensified, 






ABNORMAL MODIFICATIONS OF SOUNDS. 213 

while the sound of impulsion may be feeble or wanting. 
The sound of impulsion over the apex is weakened or 
lost as an effect of those affections of the heart which 
diminish the power of the ventricular systole. These 
affections are enlargement from dilatation, atrophy, 
fatty degeneration, myocarditis, obstruction of the coro- 
nary arteries, and softening. The systolic valvular 
sounds are also more or less weakened, but in a less 
degree than the sound of impulsion. The loss of the 
sound of impulsion over the apex renders the so-called 
first or systolic sound of the heart short and valvular 
in quality. 

Liquid effusion within the pericardium renders the 
sound of impulsion over the apex more or less weak. 
If the liquid effusion be large, only the systolic valvular 
sounds, namely, the mitral and tricuspid, are appreciable. 
Diminished power of the heart's action from other than 
cardiac diseases, involves weakness of all the heart- 
sounds, but more especially of the sound of impulsion. 

Abnormal modifications of the diastolic sound relate 
to the aortic and pulmonic sounds considered separately. 
Bearing in mind the mode of interrogating the aortic 
and the pulmonic orifice with reference to the valvular 
sound derived from each independently of the other 
{vide page 203), a comparison of the two sounds in 
diseases of the heart affords often useful information. 
Whenever, from mitral obstructive or regurgitant 
lesions, or both combined, the quantity of blood pro- 
pelled by the left ventricle into the aorta is diminished, 
the recoil of the arterial coats, after the ventricular sys- 
tole, is lessened ; consequently, the aortic segments 
expand with less force, and the aortic sound is weak- 
ened. Diminished intensity of the aortic sound thus 
10* 



214 THE HEART. 

represents an abnormal diminution of the quantity of 
blood propelled into the systemic arteries by the systole 
of the left ventricle, and this diminished intensity of 
sound is, in a measnre, a criterion of the amount of 
mitral obstruction or mitral regurgitation, or both com- 
bined. In some cases of great obstruction or regurgi- 
tation, the aortic sound is completely suppressed. How 
is weakening of this sound to be determined and meas- 
ured? By comparison with the pulmonic sound. Now, 
as will presently appear, the pulmonic sound is often 
intensified when the aortic sound is weakened. Hence, 
the former is not an accurate standard for this compari- 
son ; but it suffices for an approximation to accuracy. 
In cases of hypertrophy of the left ventricle without 
obstructive or regurgitant valvular lesions, the aortic 
sound is abnormally intensified. These cases occur 
chiefly in connection with fibroid or atrophic lesions of 
the kidneys. Intensification of the aortic sound may 
be due to increased tension of the systemic arteries with- 
out cardiac hypertrophy. 

A simpler cause of weakening or suppression of the 
aortic sound, is damage from lesions of the aortic valve. 
In proportion as the function of this valve is impaired 
by lesions, the intensity of the sound is diminished, and 
if the function of the valve be lost, the sound is want- 
ing. In these cases, the pulmonic sound being but little 
or not at all affected, it is an accurate standard for the 
comparison. 

The pulmonic sound is weakened in the rare instances 
of lesions affecting the pulmonic valve. This sound is 
oftener intensified than weakened. It is notably inten- 
sified when the right ventricle is hypertrophied, and 
especially when this hypertrophy is associated with dila- 



ABNOEMAL MODIFICATIONS OF SOUNDS. 215 

tation of the left auricle resulting from mitral obstruc- 
tion or regurgitation. These lesions weakening, as has 
just been seen, the aortic sound, the contrast between the 
aortic and the pulmonic sound in some cases of mitral 
lesions is very marked. The pulmonic sound is some- 
times loud, while the aortic sound is suppressed. 

Increased tension of the pulmonary arterial system 
may increase the intensity of the pulmonic sound, irre- 
spective of hypertrophy of the right ventricle. This 
increased tension is incident to certain pulmonary affec- 
tions — pneumonia, pleurisy, asthma, etc. This souud is 
also intensified in cases of functional palpitation and 
excitation of the heart by exercise and emotional excite- 
ment. 

In comparing the aortic and the pulmonic sound in 
disease, as in health, it is to be assumed that the ana- 
tomical relations of the aortic and the pulmonary artery 
to the second intercostal space on either side, close to 
the sternum, are not materially altered, and that the 
lungs are free from lesions in consequence of which the 
conduction of the sound on either side is abnormal. 

Returning to the systolic group of sounds, the mitral 
and the tricuspid sound may be studied separately. 
With the stethoscope applied at or a little to the left of 
the apex, the valvular sound which is heard is derived 
from the mitral valve. On the other hand, if the stetho- 
scope be applied at or near the right lower border of the 
heart, the valvular souud is derived from the tricuspid 
valve. Notable weakness or suppression of the mitral 
sound, as compared with the tricuspid, represents impair- 
ment of the function of the mitral valve ; and per con- 
tra, notable weakness or suppression of the tricuspid 
sound denotes* impairment of the function of the tricus- 



216 THE HEART. 

pid valve. Allowance in this comparison is to be made 
for a normal disparity, the mitral sound being louder 
than the tricuspid in health. 

Reduplication of Heart-sounds. — The sounds of the 
heart are said to be reduplicated when either the systolic 
or the diastolic sounds are repeated, or when both occur 
twice before the long pause or interval. Considering 
the heart-sounds as two-fold, that is, systolic and dias- 
tolic, and as represented by the whispered words Lub- 
dup, reduplication of the systolic sound is expressed by 
Lublub-dup, of the diastolic by Lub-dupdup, and ot 
both by Lublub-dupdup. 

Clinically, reduplication of the diastolic is observed 
much more frequently than reduplication of the systolic 
sound. In other words, the pulmonic and aortic sounds, 
instead of being synchronous, occur in succession. This 
may occur when the systolic sounds occur synchronously. 
The explanation is, that from increased tension of either 
the systemic or the pulmonic arteries (oftener the latter), 
the recoil of the arterial coats after the systole, and the 
extension of the sigmoid valves, take place in one artery 
sooner than in the other. If both the systolic and the 
diastolic sounds be reduplicated, the explanation which 
seems most rational is, that the two ventricles contract, 
not in exact unison, but that one contracts a little before 
the other. In systolic reduplication the mitral and the 
tricuspid sounds occur in succession instead of occur- 
ring synchronously. The sound of impulsion is not 
reduplicated. 

There is a form of functional disorder which may be 
confounded with reduplication of both sounds of the 
heart. In this disorder, with every alternate revolution 
of the heart, the sounds are weak, and the ventricular 



CAKDIAC MURMURS. 217 

systole is not represented by a radial pulse, the force of 
the contraction of the ventricle being insufficient to 
cause an appreciable pulsation in the remote arteries ; 
hence, the heart-sounds occur twice for each pulse at the 
wrist. Under these circumstances, however, the carotid 
pulse may generally, if not always, be felt with the 
weak, as well as with the stronger, ventricular contrac- 
tion, and in this way the error of confounding the 
disorder with reduplication may be avoided. 

Reduplication of the heart-sounds may occur in con- 
nection with cardiac lesions, or there may be no evidence 
of any organic affection. In the latter case the anomaly 
falls properly among the varied forms of functional dis- 
order of the heart. Whether it be connected with 
lesions or not, it has no importaut pathological signifi- 
cance. It is usually of temporary duration. 



Cardiac Murmurs. 

All adventitious abnormal sounds which are added to 
the heart-sounds, are embraced by the term cardiac mur- 
murs. Let it be borne in mind that, conventionally, 
the murmurs are never abnormal modifications of the 
heart-sounds, but always newly-produced sounds, and 
they always represent morbid conditions of either the 
heart or the blood. When due to morbid conditions of 
the blood, they are called inorganic, amemic, or haemic 
murmurs, and when they represent valvular lesions or 
changes within the heart, they are distinguished as 
organic murmurs. 

The murmurs may be distributed into three groups 
after differences in quality, namely : 1st, soft ; 2d, 
rough ; and, 3d, musical murmurs. The soft murmurs 



218 THE HEART. 

resemble the sound produced by air from the uozzle ot 
a pair of bellows, and, heuce, are often called bellows 
murmurs. Murmurs are said to be rough when their 
qualities may be expressed by such terms as rasping, 
grating, creaking, croaking, etc. They are called musi- 
cal when the sound is a musical note. The bellows 
murmurs are the most frequent, and the musical are 
more rare than the rough murmurs. The quality of a 
murmur does not in general invest it with any special 
pathological or diagnostic significance. The murmurs 
vary in pitch, being either relatively high or low. The 
variations in pitch are useful in aiding to discriminate 
different coexisting murmurs. 

This account of murmurs applies to those produced at 
the orifices or within the cavities of the heart. They 
are distinguished as endocardial murmurs. Adventitious 
sounds are, however, produced upon the external surface 
of the heart. These constitute exocardial, pericardial, 
or friction murmurs. 

Endocardial murmurs are produced by blood currents 
pursuing either a normal or an abnormal direction. 
With a familiar knowledge of these currents, and of 
their relations with the heart-sounds, the several endo- 
cardial murmurs are very easily understood, as regards 
points involved in their differentiation from each other. 
The student is, therefore, advised first to become ac- 
quainted with the blood-currents in health and in dis- 
ease. Directing the attention to the left side of the 
heart, there are two normal blood-currents, namely, the 
current from the left auricle to the left ventricle, and 
the current from the left ventricle into the aorta. These 
may be distinguished as the direct currents. The first 
is the mitral direct current, and the second is the aortic 
direct current. Two abnormal currents may occur in 



CARDIAC MURMURS. 



219 



the left side of the heart. These currents can only take 
place when the valves are rendered incompetent by 
lesions. The incompetency of the valves allows of 
regurgitation, and these abnormal currents may be dis- 
tinguished as the regurgitant currents. One of these is 
a current backward from the left ventricle into the left 
auricle, owing to incompetency of the mitral valve ; this 




Diagram representing the Abnormal Blood-currents 

Plain arrows represent currents in right side of heart. Dotted 

arrows represent currents in left side of heart. 






is the mitral regurgitant current. The other is a cur- 
rent backward from the aorta into the left ventricle, 
arising from incompetency of the aortic valve; this is 
the aortic regurgitant current. (Figs. 11 and 12.) 

What are the relations of the four currents in the left 
side of the heart with the heart-sounds? The mitral 
direct current takes place when the auricles contract. 
The contraction of the auricles precedes the ventricular 



220 



THE HEART, 



systole. The ventricular systole is synchronous with 
the systolic sounds of the heart. The mitral direct cur- 
rent, therefore, takes place just before these sounds. It 
begins after the diastolic sounds, and continues until it is 
suddenly and completely arrested by the contraction of 
the ventricle. It is, therefore, presystolic. It is obvious 
that the current cannot continue during: the ventricular 




Diagram representing the Normal Blood-currents. 

Plain arrows represent currents in right side of heart. Dotted 
arrows represent currents in left side of heart. 



contraction, that is, when the Hrst systolic sounds of the 
heart are produced. The mitral regurgitant current 
is caused by the contraction of the ventricle: the cur- 
rent, therefore, must take place with the systolic sounds 
of the heart. The aortic direct current, being caused by 
the contraction of the left ventricle, takes place with 
the systolic sounds of the heart. It is, therefore, coin- 
cident with the mitral regurgitant current. The aortic 



CARDIAC MURMURS. 221 

regurgitant current is caused by the recoil of the arte- 
rial coats upon the column of blood within the aorta 
directly after the ventricular systole, and as this recoil 
causes the diastolic aortic sound of the heart, the current 
and this sound must be coincident. 

Recapitulating the relations of the four currents with 
the heart-sounds, the aortic direct and the mitral regur- 
gitant take place with the systolic sounds — they are 
systolic currents. The mitral direct current precedes 
the systolic sounds — it is presystolic ; and the aortic 
regurgitant current takes place with the diastolic sound 
— it is diastolic. 

Analogous blood-currents take place in the right side 
of the heart, and have corresponding relations with the 
heart-sounds. These currents are the tricuspid direct, 
the tricuspid regurgitant, the pulmonic direct, and the 
pulmonic regurgitant. The pulmonic regurgitant is 
exceedingly rare in consequence of the infrequency of 
pulmonic lesions ; but the tricuspid regurgitant is not 
uncommon, and occurs without valvular lesions or 
enlargement of the heart when the right ventricle is 
distended with blood, constituting what has been called 
the "safety-valve function " of the tricuspid orifice. 

Organic endocardial murmurs are produced by the 
foregoing direct and regurgitant blood-currents, and they 
are designated by the same names; that is, they arc 
either direct or regurgitant. Thus, there are produced 
in the left side of the heart — the side in which valvular 
lesions are seated in the great majority of cases — a mitral 
direct murmur, a mitral regurgitant murmur, an aortic 
direct murmur, and an aortic regurgitant murmur. In 
the right side of the heart there may be produced 
corresponding murmurs, namely, a tricuspid direct, 



222 THE HEART. 

tricuspid regurgitant, a pulmonic direct, and a pulmonic 
regurgitant. It remains to point out the means of 
differentiating these several murmurs aside from their 
relations with the heart-sounds. 

Mitral Direct or Presystolic Murmur. — This murmur 
begins after the diastolic sounds and ends abruptly with 
the systolic sounds. Almost invariably this murmur is 
rough in quality ; occasionally, it is a soft bellows 
murmur. When rough, it is often quite loud. The 
rough quality is peculiar ; it is suggestive of vibration, 
and may be imitated by causing the lips or tongue to 
vibrate with the breath in expiration. I state the 
mechanism of this murmur, inasmuch as the explanation 
is original with me, and has not been as yet generally 
accepted. It is caused by the vibrations of the mitral 
curtains, and takes place when these curtaius are united 
at their sides, leaving a narrow buttonhole-like orifice 
through which the mitral direct current of blood flows. 
Throwing the lips into vibration with the breath, repre- 
sents not only the characteristic quality of the murmur, 
but the mode of its production. The physical condi- 
tions which are requisite generally for its production are 
a narrowed mitral orifice, and flaccidity of the mitral 
curtains. The latter of these conditions does not always 
exist in cases of mitral obstructive lesions, and, hence, 
the murmur by no means always accompanies these 
lesions. When it is considered how loud a blubbering 
sound maybe produced by the vibration of the lips with 
a feeble current of air, it is not difficult to understand 
that an intense murmur may be caused by a current of 
blood propelled by the 'comparatively weak contraction 
of the auricle. This murmur may be produced artifici- 
ally, and the mechanism of its production demonstrated 



CARDIAC MURMURS. 223 

in the following manner : Take a small India-rubber 
bag with thin walls — such as that which, when inflated, 
makes a balloon for children ; attach the opening to the 
efferent tube of a Davidson's syringe ; make a small 
orifice opposite to the attached opening of the bag ; 
immerse the bag in a basin of water, and then force a 
current of water into the bag. With a binaural stetho- 
scope, the pectoral extremity applied lightly to the bag, 
a murmur caused by the flow of water from the bag into 
the basin, is heard, resembling as closely as possible the 
usual presystolic murmur. 

Peter states that the production of a mitral presystolic 
murmur requires hypertrophy of the left auricle. 1 This 
may be doubted, in view of the fact to be stated in the 
next paragraph. Hypertrophy of the auricle, however, 
accompanies the lesion which the murmur represents, 
when the murmur is organic. 

A mitral direct murmur may be produced without 
mitral lesions, the murmur having the same character- 
istic quality as when lesions exist, and being also quite 
loud. This fact, based on clinical proof, was stated by 
me many years since, together with the explanation. 
The murmur occurs when there are aortic lesions which 
permit regurgitation. Under these circumstances, at the 
time when the auricular contraction takes place, the left 
ventricle is already filled with blood, the mitral curtains 
are floated out so as to be in contact with each other, 
and the mitral direct current passing between the cur- 
tains throws them into vibration precisely as when the 
orifice is narrowed. The vibration of the lips when 
lightly in contact, caused by the expired breath, illus- 

i TraitS des Maladies du Coeur, Paris. L883. 



224 THE HEART. 

trates the manner in which a mitral direct murmur takes 
place without mitral lesions. The murmur thus occur- 
ring without mitral lesions is not constant ; it is now 
present and now absent, depending, as it does, on the 
quantity of blood within the left ventricle at the time of 
the contraction of the auricle. It follows from what has 
just been stated, that a mitral direct murmur is not 
always a sign of mitral obstructive lesions when there is 
free aortic regurgitation. 

This murmur is limited to a circumscribed space 
above the apex of the heart. However loud the 
murmur may be in this situation, it is lost within a 
short distance either to the left or to the right of the 
apex. 1 

It is proper to state that some observers do not 
attribute a presystolic murmur to the mitral direct cur- 
rent. Donaldson, Learning, and others, suppose it to 
be, in tact, a mitral systolic murmur, the murmur 
reaching the ear before the systolic sounds are heard. 
The occurrence of this murmur in connection with aortic 
lesions, the mitral valves being sound, Keyt explains by 
supposing that the murmur may be produced at the 
aortic orifice, the murmur being heard before the sys- 
tolic sounds. There is, however, a very general agree- 
ment that the murmur is correctly called a mitral direct 
murmur. 

A mitral direct murmur is never due to a morbid 
condition of the blood. Although it occurs without 
mitral lesions, yet, inasmuch as its occurrence then re- 
quires the existence of aortic regurgitant lesions, it 
cannot be said to be an inorganic murmur. 

1 Professor Janeway states that in rare instances he has heard this 
murmur over the lower part of the scapula. 






CARDIAC MURMURS. 225 

A mitral direct murmur, as has been stated, does not 
always accompany mitral lesions. If the mitral cur- 
tains are fixed or made rigid by calcification, so that 
vibration with the mitral direct current of blood does 
not take place, either the murmur is wantiug, or its 
usual characteristic quality is absent. Feebleness of 
the auricular contraction from dilatation or over-disten- 
tion of the auricle with blood, may cause the murmur 
to disappear. Under these circumstances the murmur 
may be sometimes present and at other times absent. 
Cardiac vibration or thrill is a physical sign which 
accompanies often a well-marked characteristic presystolic 
murmur, but this sign may occur in connection with 
other valvular lesions. The thrill is presystolic in time 
when it accompanies the presystolic murmur. The thrill 
is systolic when it accompanies an aortic direct or a 
mitral regurgitant murmur, and diastolic when it accom- 
panies an aortic regurgitant murmur. 

Mitral Diastolic Murmur. — A murmur may be pro- 
duced by the mitral direct current of blood prior to the 
contraction of the left auricle; in other words, occurring 
before the presystolic murmur. From the latter this 
murmur may be distinguished as a mitral diastolic 
murmur. The flow of blood from the auricle into the 
ventricle begins directly the ventricular systole ends. 
This may be said to be a passive current until the 
auricle contracts. The contraction of the auricle makes 
the current active. Now, under certain organic condi- 
tions, the passive current produces a murmur which, in 
point of time, is diastolic — that is, directly following the 
diastolic sounds of the heart. The murmur occurs at 
the same time as an aortic regurgitant murmur. From 
the latter it is to be discriminated by its localization at 



lony 



may 



226 THE HEART. 

or near the apex of the heart, and by the absence of a 
diastolic murmur at the base. It may precede the 
characteristic presystolic murmur, differing from the 
latter in quality, or the diastolic murmur, without the 
characteristics which usually belong to the presystolic 
murmur, may continue during the whole of the 1 
pause of the heart. 

The mitral diastolic murmur (as this murmur ] 
be called) is doubtless rare, but less so, perhaps, than 
may be supposed, for two reasons : first, it is apt to be 
overlooked ; and, second, when recognized it has been 
customary to refer it to the aortic orifice. The frequency 
of the murmur and the particular physical conditions 
under which it is present, are to be determined by fur- 
ther clinical study. 

Mitral Regurgitant Murmur— Mitral Systolic Non- 
regurgitant, or Intraventricular Murmur.— The. mitral 
regurgitant murmur, synchronous with the systolie 
sounds— that is, a systolic murmur— may be soft, rough, 
or musical in quality, its intensity and pitch being vari- 
able. Aside from its relation with the systolic heart- 
sounds, it is distinguished by having its maximum ot 
intensity at or near the situation of the apex-beat. It 
may be limited to a circumscribed area, and if heard at 
a distance from the apex it is best transmitted laterally 
around the left side of the chest, on the line of the apex. 
It is often heard on the posterior aspect of the chest 
near the lower angle of the left scapula, and not infre- 
quently in the corresponding situation on the right side. 
A murmur with the systolic sounds of the heart 
heard within a limited area at the apex, may be due to 
roughness of the endocardial membrane without mitral 
incompetency, and, consequently, without a mitral regur- 






CARDIAC MURMUES. 227 

gitant current. This is a mitral systolic non-regurgitant 
murmur. It may, also, be called au intra-ventricular 
murmur, being produced, uot at the mitral orifice, but 
within the ventricle. This murmur cannot always be 
discriminated from a feeble mitral regurgitant murmur. 
If, however, a mitral murmur be conducted laterally 
for some distance to the left of the apex, and if it be 
heard on the back, it probably denotes mitral regurgita- 
tion. A mitral systolic, nou-regurgitant, or intra-ven- 
tricular murmur is the murmur present in endocarditis. 
It may be caused, as has been demonstrated by my col- 
league, Prof. Janeway, by a tendinous cord extending 
from the inner wall on one side to the opposite side of 
the ventricular cavity. This occurs as a congenital 
anomaly. Aneurism of the heart may be so situated as 
to give rise to a murmur simulating a mitral systolic 
murmur. Cardiac aneurism, however, is exceeding rare. 
Aneurism of the thoracic aorta may cause a murmur 
which, transmitted through the heart, simulates a mitral 
systolic murmur. 

The impulse of the apex of the heart against the adja- 
cent portion of the lung sometimes forces the air from 
the air- vesicles sufficiently to give rise to a blowing" 
sound occurring with each ventricular systole. This is 
liable to be confounded with an endocardial murmur. 
Produced in the way just stated, it is heard only during 
the act of inspiration, and especially at the end of this 
act. 

A mitral systolic murmur is rarely, if ever, due to an 
abnormal condition of the blood, without any anatomi- 
cal change in the valve or endocardial membrane. Con- 
ditions of the blood, however, which arc favorable for 






228 THE HEART. 

the production of inorganic murmur may intensify this 
murmur, as well as any of the organic murmurs. 

It has been conjectured that a mitral systolic murmur 
may be produced by a purely functional incompetency 
of the mitral valve, permitting a mitral regurgitant 
current, no actual lesion of the valve or the mitral 
orifice existing. In this way are explained the occur- 
rence of a mitral systolic murmur and its disappearance 
after a remoter duration, without other evidence of en- 
docarditis or any organic affection of the heart. It 
does not enter into the scope of this work to discuss the 
validity of this explanation. The fact, however, that a 
mitral systolic murmur may exist, continue for weeks 
or mouths, and even for years, and disappear, the mur- 
mur being neither accompanied nor followed by signs 
or symptoms denoting organic disease, is an important 
fact to be borne in mind with reference to diagnosis and 
prognosis. The temporary occurrence of this murmur 
in chorea has been attributed to functional incompetency 
of the valve due to irregular contraction of the papil- 
lary muscles. 

Aortic Direct Murmur. — This murmur, like the mitral 
systolic murmurs, occurs with the systolic sounds of the 
heart. Of the organic murmurs on the left side of the 
heart, the mitral systolic murmurs and the aortic direct 
murmur are synchronous, the others having different 
relations with the heart-sounds. The aortic direct mur- 
mur differs from the mitral systolic murmurs in having 
its maximum of intensity at the base of the heart. It 
is loudest in the second intercostal space near the 
sternum. As a rule, it is louder in this intercostal 
space on the right than on the left side ; this rule, 
however, has frequent exceptions. It is transmitted 



CARDIAC MURMURS. 229 

better and further upward than downward. It is 
always heard over the carotid artery ; and it is some- 
times louder over this artery than at the base of the 
heart. As a murmur may be produced within the 
carotid artery, it is desirable to determine, when a sys- 
tolic murmur is heard at the base, whether the carotid 
murmur is a transmitted murmur or not. This point 
is to be settled by comparing the murmur over the 
carotid with the murmur at the base, as regards quality 
and pitch. If the quality and pitch of the murmur in 
the two situations be the same, it is fair to consider the' 
murmur in the carotid as not produced within the artery, 
but conducted by the blood-current from the aortic 
orifice. 

An aortic direct murmur is frequently inorganic. It 
is to be considered as such when it is not associated with 
an aortic regurgitant murmur; when the heart is not 
enlarged ; when anseniia is shown by the presence of 
murmurs in the large arteries ; and when there is the 
venous hum 1 in the neck — these physical evidences of 
anaemia being associated generally, not invariably, with 
pallor, and with symptoms pointing to impoverishment 
of the blood. Moreover, an inorganic murmur is very 

1 To obtain the venous hum (bruit de diable), cause the patient to turn 
the head as far as practicable to the left, and apply the stethoscope to the 
neck on the right side, near the clavicle, behind the sterno-cleido-mas- 
toid muscle. Press the stethoscope with different degrees of force before 
concluding that the murmur is wanting. The venous hum is continu- 
ous, and closely resembles the sound of the humming-top. Gentle pres- 
sure with the finger above the stethoscope, so as to interrupt the flow of 
blood in the veins, causes the murmur at once to cease. The fact is 
proof of its being a venous murmur. A systolic murmur heard with 
the stethoscope applied to the neck, is an arterial murmur, which may 
either be produced within the artery, or transmitted from the aortic 
orifice. An arterial and a venous murmur in the neck often coexist. 
11 



230 THE HEART. 

rarely rough, and it is variable in its occurrence, being 
at one time present and at another time absent, whereas 
an organic murmur is, in general, constant. Associated 
with other evidence of anaemia, au aortic direct murmur 
may, nevertheless, be organic, but, under the differenti- 
ating circumstances just stated, the lesion represented by 
the murmur, if the murmur be organic, must be innocu- 
ous, so that it is not of great practical importance to 
determine whether the murmur be or be not inorganic. 

Like the other organic murmurs, an aortic direct 
murmur varies in different cases in intensity, quality, 
and pitch. An organic aortic direct murmur, per se, 
does not denote always aortic obstruction. It may be 
due simply to roughness of the membrane at or above 
the aortic orifice. 

Aortic Regurgitant Murmur — Aortic Diastolic Non- 
regurgitant Murmur, or a Prediastolic Murmur. — An 
aortic regurgitant murmur occurs with the second dias- 
tolic sounds of the heart. It is almost always heard at 
the base of the heart, but, in some instances, when not 
appreciable at the base, it is heard a little below the 
base, namely, near the sternum on the left side on a 
level with the fourth costal cartilage. In some instances, 
however, the maximum of intensity is in a corresponding 
situation on the right side. In the latter situations it 
has generally its maximum of intensity. It is trans- 
mitted best in a downward direction, being often heard 
at the apex, and sometimes considerably below this point. 
It is never inorganic. It is usually not intense, low in 
pitch, and soft ; but it may be loud, high, rough, or 
musical. 

A short murmur is sometimes produced by the retro- 
grade movement of the blood-current within the aorta, 



CARDIAC MURMURS. 231 

the aortic valve being intact, and regurgitation not, 
therefore, taking place. This murmur is due to rough- 
ening of the lining membrane of the aorta by atheroma 
or calcareous deposit, and it is always preceded by an 
aortic direct murmur. It occurs directly after the systole, 
and ends with the second sound. Although of such 
brief duration, it is distinctly recognizable and distin- 
guished from the preceding aortic direct murmur. I 
have long been accustomed to demonstrate this murmur 
in private teaching, and have called it an aortic diastolic 
non-regurgitant murmur. A better name is a predias- 
tolic murmur. It cannot be said to have much practical 
importance, inasmuch as the lesion giving rise to it is 
represented by the aortic direct murmur which precedes 
it. This murmur may be associated with a true regur- 
gitant murmur. This is the explanation of a diastolic 
murmur which is rough before and soft after the aortic 
second sound. 

Coexisting Endocardial Murmurs. — The murmurs re- 
ferable to the left side of the heart, which have been 
considered, are often found in combination ; two or three 
may coexist, or all of them may be present. Moreover, 
with one or more of these murmurs may be associated 
murmurs referable to the right side of the heart. Hav- 
ing become familiar with their relations with the heart- 
sounds, and other points involved in their differentiation, 
it is not difficult to recognize them in combination. The 
mitral murmurs are not infrequently associated. The 
mitral direct, being presystolic, ends with the systolic 
sounds, and the mitral systolic or regurgitant begins 
with these sounds; the systolic sounds, as it were, divide 
these two murmurs. These murmurs almost invariably 
differ from each other in pitch and quality. The pres- 



232 THE HEART. 

ence of both, in fact, assists, rather than obstructs, the 
recognition of each. The aortic direct and the aortic 
regurgitant murmur, also, are often associated. A mur- 
mur then accompanies the systolic and the diastolic 
sounds of the heart ; the two murmurs follow in the 
same rhythmical order as the two groups of heart-sounds. 
These murmurs, when associated, can only be confounded 
with pericardial friction-sounds. 

The combination of the aortic direct and the mitral 
systolic murmur alone offers any difficulty. These two 
murmurs have the same relation with the heart-sounds; 
they are both systolic. How is it to be determined 
when a systolic murmur is heard both at the base and 
apex, whether a mitral murmur is transmitted to the 
base, or an aortic murmur is transmitted to the apex; in 
other words, how is it to be decided whether two mur- 
murs are present or only one murmur? If these two 
murmurs coexist, generally the circumstances which dis- 
tinguish each separately can be ascertained. Thus, the 
aortic murmur is transmitted into the carotid artery, and 
the presence of that murmur is then established; the 
mitral regurgitant murmur is often transmitted laterally 
around the chest or heart at the lower angle of the 
scapula, and then the presence of that murmur is estab- 
lished. But there are additional points, namely, the 
murmur at the base and that at the apex generally differ 
sufficiently in pitch or quality to render it evident that 
there are two murmurs ; and generally at a situation in 
the pnecordia between the base and apex, both murmurs 
may be either lost or become notably weakened. Atten- 
tion to these points in most instances divests the problem 
of difficulty. 

Mitral and aortic lesions are often of a character to 



CARDIAC MURMURS. 233 

give rise to only one murmur at either of these orifices. 
A mitral direct murmur not infrequently is present 
without the mitral regurgitant, and the reverse of this is 
frequent. So, either an aortic direct or an aortic regur- 
gitant murmur may exist without the other. 

Tricuspid Direct Murmur. — The lesions which are 
requisite for this murmur very rarely occur at the tri- 
cuspid orifice ; hence, this murmur is exceedingly rare. 
It is to be distinguished from the mitral direct murmur 
by its localization being, not at the apex, but at the right 
border of the heart. The mitral direct and the tricus- 
pid direct murmur may coexist; an instance of this kind 
has fallen under my observation. In that instance a 
presystolic murmur, with the characteristic blubbering 
quality, was heard both at the apex and at the right side 
of the heart. 

Tricuspid Regurgitant Murmur. — This murmur is 
not of infrequent occurrence. Tricuspid regurgitation 
occurs often when, the right ventricle is considerably 
dilated, without the existence of lesions of the valve. 
A tricuspid regurgitation current, however, does not 
invariably give rise to an appreciable murmur. This 
fact is shown by the occurrence of a venous pulse in the 
neck, due to tricuspid regurgitation, when no murmur 
can be heard. 

The tricuspid regurgitant murmur, of course, occurs 
with the first or systolic sound, being systolic like the 
mitral regurgitant murmur, and the latter generally 
coexists. It is distinguished from the mitral regurgitant 
by its localization at the right inferior margin of the 
heart, and its transmission to the right rather than to 
the left. The coexistence of the mitral and the tricuspid 
regurgitant murmur is determined by the differences in 






234 THE HEART. 

pitch and quality between a systolic murmur at the apex 
aud at the right margin of the heart. A venous pulse, 
synchronous with the first sound of the heart, points to 
tricuspid regurgitation, and although sometimes present 
without a tricuspid regurgitant murmur, when present 
it is corroborative evidence of the latter. 1 

Pulmonic Direct Murmur. — A pulmonic direct mur- 
mur, if organic, is generally connected with congenital 
lesions. The pulmonic direct and the aortic direct cur- 
rent of blood taking place at the same instant, the mur- 
murs representing both are, of course, systolic. How 
is the pulmonic to be distinguished from the aortic direct 
murmur? The pulmonic murmur is heard in the left 
second intercostal space close to the sternum ; but this is 
not very distinctive, inasmuch as, not infrequently, the 
aortic murmur is loudest in that situation. The essen- 
tial point of distinction is this : the pulmonic direct 
murmur is not transmitted into the carotid artery, 

1 Pulsation of the cervical veins is a not infrequent sign in cases of 
enlargement of the right side of the heart. The pulsation in the veins 
is visible, but very rarely appreciable by the touch. It is to be distin- 
guished from pulsation of the arteries of the neck. This is easily done 
by finding that pressure just above the clavicle sufficient to interrupt the 
flow of blood in the veins, but not in the arteries, abolishes the pulsa- 
tion. The venous pulse is generally due to a tricuspid regurgitant cur- 
rent, and is therefore caused by the contraction of the right ventricle. It 
may, however, be caused by the contraction of the right auricle. If 
caused by the contraction of the right ventricle, giving rise to tricuspid 
regurgitation, the venous pulse is synchronous with the carotid pulse, the 
systolic sounds of the heart, and the apex beat. If caused by the con- 
traction of the right auricle, the venous pulse precedes the carotid pulse ; 
it is presystolic. A venous pulse thus may be either ventricular or 
auricular, and the differentiation is easily. made. There may be both 
a ventricular and an auricular venous pulse, the one synchronous with, 
and the other preceding, the carotid pulse. Pulsation is sometimes 
observed in other veins than those of the neck — the brachial, femoral, 
and even veins still more remote from the heart. 



CARDIAC MURMURS. 235 

whereas the aortic direct murmur is always thus trans- 
mitted. If an aortic direct and a pulmonic direct mur- 
mur coexist, both being organic, the combination is to 
be ascertained by finding that the murmur in the second 
intercostal space on the right side differs from that on 
the left side in pitch or quality sufficiently to show the 
presence of these murmurs, the one on the right side 
being transmitted to the carotid artery. 

An inorganic or functional pulmonic direct murmur 
is of frequent occurrence in cases of anaemia. It is fre- 
quently associated with an inorganic aortic direct mur- 
mur, the presence of the two murmurs being evidenced 
by a difference in pitch. The theory of Naunyn, that 
the systolic functional murmur heard in the left second 
intercostal space near the sternum, and generally referred 
to the pulmonic orifice, is not a pulmonic, but a mitral 
regurgitant murmur conducted by the dilated appendix 
of the left auricle, has been elaborately advocated by Dr. 
Balfour, of Edinburgh. This theory is so strained and 
fanciful, that it hardly deserves the discussions which it 
has received from others. It is certain that a mitral 
regurgitant murmur due to mitral lesions has its maxi- 
mum of intensity at or near the apex of the heart. 
Why should a murmur hypothetically referred to func- 
tional incompetency of the mitral valve be heard above 
the base of the heart and not at the apex ? 

Pulmonic Regurgitant Murmur. — This murmur is 
exceedingly rare in consequence of the infrequency of 
pulmonic regurgitant lesions. It occurs, of course, like 
the aortic regurgitant, with the second or diastolic 
sound. Its presence can only be determined when other 
signs go to show the existence of pulmonic and the 
absence of aortic lesions. This murmur, as well as the 






236 THE HEART. 

aortic regurgitant, can never be iuorganic, its presence 
being proof of a regurgitant current of blood from in- 
competency of the pulmonic valve. 1 

Facts of practical importance in relation to the endo- 
cardial murmurs, are embraced in the following state- 
ments : 

The question as to a murmur being organic or inor- 
ganic, relates chiefly, if not entirely, to the aortic direct 
and the pulmonic direct murmur, other murmurs being 
almost invariably organic. 

Associated signs and symptoms generally warrant a 
definite conclusion whether an aortic direct or a pul- 
monic direct murmur be, or be not, organic, and under 
the circumstances which render it difficult to decide 
this question positively, a positive decision is not of 
much immediate practical consequence. 

Valvular lesions, whether obstructive, regurgitant, or 
innocuous, are so uniformly represented by murmur, 
that, as a rule, absence of lesions may be predicated on 
the absence of murmur. 

With a practical knowledge of the different organic 
murmurs, the situation of lesions at either of the ori- 
fices of the heart, or their existence at two or more of 
these orifices, may be demonstratively determined. 

By means of the murmurs, with other signs, it may 
be determined demonstratively whether the lesions 
involve obstruction or regurgitation, or both, or, on the 
other hand, that they are, as regards immediate patho- 
logical effects, innocuous. 

The murmurs do not afford definite information as to 

1 I have met with an instance in which it existed, and was attributed 
to pressure from without. 



CARDIAC MURMURS. 237 

the amount of obstruction or regurgitation, in other 
words, as to the pathological importance or gravity of 
lesions, when they are not iuuocuous. No positive con- 
clusions on this point of view are to be drawn from the 
intensity of murmurs, their pitch or their quality. As 
a rule, murmurs which are weak, more than those 
which are loud, represent grave lesions. 

Pericardial or Friction Murmur. — A. pericardial or 
friction murmur is produced by the rubbing together of 
the surfaces of the pericardium in the systolic and dias- 
tolic movements of the heart. In the vast majority of 
the cases in which this murmur occurs, it denotes either 
the presence of recent lymph which renders the surfaces 
more or less adhesive, or roughening from lymph which 
has become dense and adherent ; its diagnostic signifi- 
cance, therefore, relates almost exclusively to pericar- 
ditis. In this relation it is of great practical impor- 
tance. 

This exocardial murmur is to be discriminated from 
the endocardial murmurs. The points involved in the 
discrimination are as follows : The murmur is double, 
that is, a murmur accompanies both the ventricular sys- 
tole and diastole. It can, therefore, only be confounded 
with an aortic direct and an aortic regurgitant murmur 
in combination. The quality of the murmur is sugges- 
tive of rubbing or friction. It is sometimes a feeble 
grazing sound ; in other instances it is loud and rough. 
When rough, the quality is expressed by such terms as 
rasping, grating, creaking, etc. Although accompany- 
ing both the systolic and diastolic sounds of the heart, 
it has not that uniform, fixed relation to these sounds 
which characterizes the aortic direct and the aortic re- 
gurgitant murmur ; it is not in definite accord with the 
11* 



238 THE HEART. 

heart-sounds. Moreover, in intensity it varies with the 
successive movements of the heart, being louder with 
some revolutions than with others, in this regard differ- 
ing notably from the endocardial murmurs. It is not 
heard without the prsecordia, as a rule, and is often 
limited to a part of the precordial region ; whereas, 
certain of the endocardial murmurs, namely, the mitral 
regurgitant and the aortic direct, are often heard at a 
considerable distance from the heart. Firm pressure 
with the stethoscope and often a forced expiration inten- 
sify the murmur. Its source seems very near the sur- 
face of the chest. In this respect it differs notably 
from endocardial murmurs, the latter appearing to come 
from a certain distance within the chest. This point of 
distinction is very appreciable, especially if, as often 
happens, a friction murmur be associated with an endo- 
cardial murmur. 



CHAPTER VIII. 

THE PHYSICAL DIAGNOSIS OF DISEASES OP THE 
HEAET AND OP THOKACIC ANEUKISM. 

Enlargement of the heart by hypertrophy and dilatation — Valvular 
lesions, mitral, aortic, tricuspid, and pulmonic — Fatty degeneration 
and softening of the heart — Endocarditis— Pericarditis — Functional 
disorders— Thoracic aneurism. 

The morbid physical conditions incident to the dif- 
ferent diseases of the heart, and the signs representing 
these conditions, have been considered in the preceding 
chapter. The diseases are now to be considered with 
reference to the assemblage of signs on which the physi- 
cal diagnosis of each is to be based. Most of the dis- 
eases of the heart may be diagnosticated by means of 
physical signs. A few cardiac lesions do not admit of a 
physical diagnosis, and they do not, therefore, claim 
consideration in this work. The following are the 
affections which will form separate headings in this 
chapter : Enlargement of the Heart by Hypertrophy 
and by Dilatation, Valvular Lesions, Fatty Degenera- 
tion and Softening of the Heart, Endocarditis, Pericar- 
ditis, and Functional Disorders. Having considered 
these affections, the physical diagnosis of thoracic aneu- 
rism will be the concluding topic. 

Enlargement of the Heart by Hypertrophy and by 
Dilatation. — Physical exploration to determine the size 
of the heart has three objects, namely, to determine, 
first, that the size of the heart is normal, or second, 
that the heart is enlarged, and, third, the degree of 



240 DISEASES OF THE HEART. 

enlargement. These objects are obtainable by means of 
percussion and auscultation. 

The heart is of normal size when the apex-beat is in 
its normal situation, that is, in the fifth intercostal space, 
a little within a vertical line passing through the nipple 
(the liuea mammillaris) ; when the superficial cardiac 
space is not enlarged, as shown by percussion and by 
auscultation of the voice (vide page 197), and when per- 
cussion shows the lateral borders of the heart to be 
situated normally, namely, on the left side a little within 
the line of the nipple, and on the right side of a finger's 
breadth to the right of the right margin of the sternum. 
These points of evidence warrant a positive conclusion 
that the heart is not enlarged. 

The fact of an enlargement and its degree are deter- 
minable by an abnormal situation of the apex, together 
with an increase of the superficial cardiac space and ex- 
tension of the lateral boundaries of the deep cardiac 
space, especially on the left side. 

In cases of slight or very moderate enlargement, the 
apex is situated a little without the linea mammillaris, 
but not below the fifth intercostal space. A somewhat 
greater enlargement lowers the apex to the sixth inter- 
costal space, and removes it further without the line of 
the nipple. In greater degrees of enlargement the apex 
is lowered to the seventh, eighth, or ninth intercostal 
space, and generally further removed to the left. The 
lowering of the apex and the removal to the left, are 
not uniformly proportionate to each other. As a rule, 
if the right side of the heart be more enlarged than the 
left, the apex is removed without the linea mammillaris 
further than when the enlargement of the left side of 
the heart predominates, and when the latter is the case, 



ENLARGEMENT OF THE HEART. 241 

the apex is lowered out of proportion to its removal 
without that line. The relatively abnormal situation 
downward and to the left, thus, is evidence of the en- 
largement predominating in either the right or the left 
side of the heart. 1 Generally the situation of the apex 
is apparent to the touch and frequently to the eye. In 
some instances, however, the impulse can neither be seen 
nor felt. How is its situation to be then ascertained ? 
Auscultation furnishes a ready and reliable mode of 
determining this point. The situation in which the first 
sound of the heart has its maximum of intensity, as 
ascertained by means of the stethoscope, corresponds to 
the situation of the apex. This is hardly less definite 
than the presence of an appreciable impulse. 

In determining the fact of enlargement and its degree 
by the abnormal situation of the apex, causes of the 
latter which are extrinsic to the heart are to be elimi- 
nated. The apex is removed to the left of its normal 
situation by enlargement of the left lobe of the liver, 
abdominal tumors, hydroperitoneum, the pregnant 
uterus, and gastric tympanites. These extrinsic condi- 
tions are to be excluded or due allowance made for them. 
In some cases in which one or more of these extrinsic 
causes of displacement may exist, the apex is carried 
into the axillary region. It is to be borne in mind that 

i In some diagrammatic illustrations — e. g., three of Weil and Van 
Dusch — the relatively greater removal of the apex, either to the left or 
downward, indicating that the enlargement predominates either in the 
right or the left ventricle, is represented as precisely the reverse of the 
statements here made. In these illustrations the extension of the area 
occupied by the heart is in a direction to the right if the right ventricle 
be predominantly enlarged, and to the left if the enlargement predomi- 
nates in the left ventricle. The illustrations are based on theoretical 
conclusions. Clinical observation shows them to be erroneous. 



242 DISEASES OF THE HEART. 

these causes of displacement may exist when there is 
more or less enlargement of the heart. All these causes, 
while they displace the apex to the left, do not lower, 
but tend to raise it above, its normal situation. On the 
other hand, an aneurismal or other tumor, situated above 
the heart, may press downward the organ, and in this 
way the apex is more or less lowered. 1 

The superficial cardiac space is increased in proportion 
as the heart is enlarged. The extent of this increase 
is easily determined by percussion and auscultation 
Within this space there is notable dulness on percussion. 
The degree of dulness is greater than within the super- 
ficial cardiac space iu health, and this degree of dulness 
is proportionate to the greater area in which the heart 
is uncovered of lung. It is easy to delineate by percus- 
sion on the chest the boundary of the anterior border of 
the upper lobe of the left lung ; in other words, of the 
oblique line which is the hypothenuse of the right- 
angled triangle representing the superficial cardiac space 
in health and in disease. The area of the superficial 
cardiac space is also not less readily and precisely ascer- 
tained by auscultation of the voice ; the limits of the 
lung within the prsecordia are denoted by an abrupt ces- 
sation or notable diminution of the vocal resonance. In 
women with large mamma? auscultation is more availa- 
ble for this object than percussion. The extent to which 
the superficial cardiac space is enlarged is a good crite- 
rion of the degree of the enlargement of the heart. 

In proportion as the heart is enlarged, the situation 
of the left border is to the left of the linea mammillaris. 



1 Professor Janeway states that he has known the apex lowered by 
an unusually long first portion of the aortic arch. 



ENLARGEMENT OF THE HEART. 243 

Its situation is determined by percussion. Dullness, 
although not great, is sufficiently distinct within the 
deep cardiac space, and the line which denotes the left 
border of the heart is easily delineated on the chest. 
This statement holds true with respect to the right bor- 
der of the heart; but this border, even when the enlarge- 
ment of the heart is great, is removed comparatively 
little to the right of its normal situation. By means of 
percussion the boundaries of the prsecordia as enlarged 
by the increased size of the heart may be determined 
and measured. In making this statement, it is assumed 
that the lungs are not diseased, and that the chest is not 
deformed. Shrinkage of the upper lobe of the left lung 
may enlarge the superficial cardiac space, and cause dis- 
placement of the heart. The latter is an effect of the 
presence of pleuritic effusion, and it may follow its re- 
moval. In cases of deformity from spinal curvature, 
to determine the fact of enlargement of the heart, or its 
degree, is not always an easy problem. 

There is a liability to error in localizing the apex in 
some cases of enlargement. Owing to the blunted form 
of the apex, especially when the enlargement is chiefly 
of the right side of the heart, the apex-beat may be 
feeble. It is liable to be overlooked, and a stronger 
impulse in the intercostal space above the apex mistaken 
for the apex-beat. Of course, the lowest impulse is the 
apex-beat. Careful palpation, and finding by ausculta- 
tion the spot where the first sound has its maximum of 
intensity, will prevent this error. 

Enlargement of the heart, and the degree of enlarge- 
ment having been ascertained, it is to be determined 
whether hypertrophy or dilatation predominate. If 



244 DISEASES OF THE HEART. 

the enlargement be slight or moderate, it may be a 
question whether hypertrophy or dilatation exist alone. 
As a rule, if either of these two forms of enlargement 
exist without the other, it is hypertrophy, for, with rare 
exceptions, hypertrophy precedes dilatation. If the 
enlargement be very great, as a rule, dilatation predom- 
inates, for the capability of hypertrophic increase of size 
has its limit, and an increase of size beyond this limit 
must be due to dilatation. 

The signs, denoting on the one hand hypertrophy, 
aud on the other hand dilatatiou, relate to the impulses 
of the heart and to the heart-sou uds. With a moderate 
enlargement, hypertrophy is to be inferred from an 
abnormal force of the apex-beat, and an intensification 
of the systolic sounds, especially the sound of impulsion 
over the apex. With a considerable or great enlarge- 
ment, if hypertrophy predominate, the apex-beat may 
be abnormally strong and prolonged, but, as already 
stated, owing to its blunted form, the beat is sometimes 
weak and scarcely appreciable ; the increased power of 
the ventricular contractions, representing the hypertro- 
phy, is then to be determined by impulses in the inter- 
costal spaces above the apex. These impulses are some- 
times present in each intercostal space between the apex 
and the base, and they are abnormally strong in pro- 
portion as hypertrophy predominates. Still more 
marked evidence of hypertrophy is sometimes obtained 
when the hand is placed over the praecordia; a powerful 
heaving movement is felt. The increased power of the 
ventricular contractions may, in some cases, be in this 
way appreciated somewhat as if the heart were held in 
the hand. In cases of considerable or great hypertro- 
phic enlargement, the intensity of the sound of impul- 



VALVULAR LESIONS. 245 

sion over the apex is notably increased ; it is prolonged, 
and its booming quality is more marked than in health. 
Not infrequently it is accompanied by a metallic ringing 
sound, or tinnitus. 

Moderate enlargement by dilatation is characterized 
by abnormal weakness of the apex-beat and of the sys- 
tolic sounds over the apex. Cases, however, of simple 
dilatation are rare. If the enlargement be considerable 
or great, and dilatation predominate, all the impulses 
are weak, as compared with the cases in which hyper- 
trophy predominates, and the sound of impulsion over 
the apex is diminished or nil, the feeble, short, mitral 
valvular sound either supplanting or predominating 
over the sound of impulsion. These points of distinc- 
tion are marked in proportion as dilatation predomi- 
nates. 

In the great majority of the cases of enlargement of 
the heart, valvular lesions coexist. These coexisting 
valvular lesions are represented by endocardial mur- 
murs, and they may generally be excluded by the 
absence of the latter. In most of the cases in which 
enlargement exists without valvular lesions, it is asso- 
ciated with either pulmonary emphysema or chronic 
Bright's disease. 

Valvular Lesions. 

The physical diagnosis of valvular lesions embraces 
their localization at the different orifices within the 
heart, and the determination of their character as giving 
rise to obstruction and regurgitation, or of their iunocu- 
ousness in these respects. These objects of diagnosis 
involve the endocardial murmurs and the abnormal 



246 DISEASES OF THE HEART. 

modifications of the heart-sounds which were considered 
in the preceding chapter. Lesions of the different 
orifices, namely, the mitral, aortic, tricuspid, and pul- 
monic, will be considered separately. 

Mitral Lesions. — The lesions at the mitral orifice are 
represented by the mitral murmurs — the mitral direct 
murmur, the mitral regurgitant, the mitral systolic nou- 
regurgitaut or intra-ventricular, and the mitral diastolic 
murmur. Mitral obstructive lesions exist whenever the 
mitral direct murmur is present, with an exception 
already stated and explained [vide page 222), namely, 
this murmur is present in some cases in which the 
mitral valve is intact, aortic lesions, giving rise to free 
regurgitation, existing in these cases. These excep- 
tional instances are rare, and I am not aware that any 
have been reported except by myself. 

Mitral regurgitant lesions exist whenever a mitral 
murmur which is truly regurgitant is present. A sys- 
tolic murmur having its maximum of intensity at or 
near the apex, transmitted laterally for a certain dis- 
tance beyond the apex on the left side of the chest, and 
heard on the back near the lower angle of the scapula, 
generally, if not invariably, denotes a regurgitant cur- 
rent; but a systolic murmur limited to a small area 
around the apex, or to the superficial cardiac space, is 
not proof of regurgitation. A truly regurgitant mur- 
mur, however, may be too feeble to be transmitted be- 
yond the apex; the proof of regurgitation must then 
be based on other evidence associated with the murmur 
namely, on enlargement of the heart and abnormal 
modifications of the heart-sounds. 

Mitral obstruction may exist without incompetency 
of the mitral valve, as shown by the presence not very 



VALVULAR LESIONS. 247 

infrequently of a mitral direct, without a mitral regur- 
gitant, murmur. The converse of this is of more fre- 
quent occurrence ; that is, regurgitation may exist 
without obstruction. The absence, however, of a mitral 
direct murmur is not positive proof against mitral 
lesions, for, as has been seen, the production of a char- 
acteristic mitral direct murmur requires the obstruction 
to be caused by an adherence of the mitral curtains at 
their sides, the curtains being sufficiently flexible to 
vibrate with the passage of the mitral direct current of 
blood. If these conditions for the production of the 
murmur do not exist, there may be no murmur pro- 
duced by the mitral direct current ; or, if a murmur be 
present, it is devoid of the usual characteristic quality. 
Mitral obstruction and regurgitation not infrequently 
coexist, as shown by the presence of both the mitral 
direct and the mitral regurgitant murmur. A mitral 
murmur, produced by a mitral direct current, but dias 
tolic in point of time, is sometimes, as has been seen 
(vide page 225), observed in connection with mitral 
lesions. The significance of this murmur, except that 
it denotes mitral lesions, is not yet ascertained. 

The mitral murmurs do not, per se, denote the amount 
of obstruction or regurgitation, or of both combined. 
Information with reference to these points may be 
derived, in the first place, from a comparison of the 
aortic with the pulmonic second sound. The amount 
of obstruction or regurgitation, or both, is great in pro- 
portion as the aortic sound is weakened. Per contra, 
there can be but little obstruction or regurgitation if 
the aortic and the pulmonary second sound preserve 
completely or nearly their normal relation to each other 
in respect of intensity. Information may, in the second 



248 DISEASES OF THE HEART. 

place, be obtained by directing attention to the mitral 
valvular sound (vide page 215). In proportion as the 
function of the mitral valve is compromised by lesions, 
the mitral valvular sound at the apex will be weakened. 
In some cases this sound is lost, the sound of impulsion 
remaining. 

Enlargement of the right side of the heart, which 
results from mitral obstructive and regurgitant lesions, 
is a criterion of the amount of obstruction and regurgi- 
tation taken in connection with the length of time in 
which they have existed. Hypertrophic enlargement 
of the right ventricle intensifies the pulmonic second 
sound, and allowance must be made for this modifica- 
tion in determining, by a comparison of the pulmonic 
and the aortic sound, the degree in which the latter is 
weakened. Attention is to be given to the tricuspid 
valvular sound (vide page 214). The intensity of this 
sound is, in some measure, a criterion of the power of 
the right ventricular systole. 

Aortic Lesions. — Lesions are localized at the aortic 
orifice by the aortic murmurs, namely, the aortic direct 
and the aortic regurgitant murmur. Aortic obstructive 
lesions give rise to an aortic direct murmur; but it 
must be considered, in the first place, that an aortic direct 
murmur may be inorganic, and, in the second place, 
that, if the murmur be organic, it may be produced by 
lesions which occasion no obstruction, and are conse- 
quently innocuous. The existence of obstructive lesions 
must be determined by evidence added to the presence 
of the murmur. This evidence is either diminished 
intensity or suppression of the aortic second sound, and 
enlargement of the left ventricle. If the lesions which 
occasion obstruction are of a character to diminish or 



VALVULAE LESIONS. 249 

arrest the movements of the aortic valve, the aortic 
second sound will be either weakened or lost. If val- 
vular lesions be limited to the aortic orifice, the degree 
of enlargement of the left ventricle is a criterion of their 
pathological importance. 

Regurgitant lesions at the aortic orifice give rise to 
an aortic regurgitant murmur. This murmur, of course, 
is always proof of regurgitation ; but the murmur gives 
no definite information concerning the amount of incom- 
petency of the aortic valve. A loud murmur may be 
produced by a regurgitant stream so small as to be, for 
the time, insignificant ; and, on the other hand, a large 
regurgitant current may give rise to a feeble murmur. 
The extent to which the valve is damaged by the 
lesions, is to be determined, first, by either weakness or 
suppression of the aortic sound, and, second, by the 
degree of enlargement of the left ventricle. 

Aortic obstructive and regurgitant lesions are often 
associated. An aortic direct and an aortic regurgitant 
murmur are then both present, with a weakened aortic 
sound or its suppression, and enlargement of the left 
ventricle according to the amount of the obstruction 
and regurgitation, together with the length of time dur- 
ing which the latter have existed. These eifects, and 
not the intensity, nor the pitch, nor the quality of the 
murmurs, are indicative of their pathological impor- 
tance. 

Mitral and aortic lesions often coexist, giving rise to 
two, three, or four of the obstructive and regurgitant 
murmurs in the left side of the heart. In addition to 
the murmurs in these cases, the effects of the combined 
lesions are shown in the modification of the heart-sounds, 
and enlargement of both sides of the heart. 



250 DISEASES OF THE HEART. 

Tricuspid Lesions. — Tricuspid obstructive lesions are 
exceedingly rare. A few instances of the kind of 
obstruction which is represented by a tricuspid direct or 
presystolic murmur, have been reported. One instance 
has fallen under my observation. In this case, as in 
the other instances which have been reported, the tri- 
cuspid were associated with mitral lesions : hence, in 
localizing an obstructive lesion at the tricuspid orifice, 
the presence of the presystolic murmur on each side ot 
the heart — that is, the coexistence of mitral and tricuspid 
direct murmur — is to be determined. This point has 
already been considered (vide page 233). 

Tricuspid regurgitation is not uncommon. Generally 
the insufficiency is caused by dilatation of the right 
ventricle occurring as an effect of mitral regurgitant or 
obstructive lesions. Tricuspid regurgitation is not 
always represented by murmur; and when a tricuspid 
regurgitant murmur is present, it is to be discriminated 
from a coexisting mitral regurgitant murmur. This 
point has been considered (vide page 233). A sign of 
free tricuspid regurgitation with hypertrophy of the 
right ventricle, is pulsation of the liver, which may be 
seen and felt. This pulsation is sometimes notably 
strong. If the liver be enlarged, the pulsation may be 
communicated to the greater part of the abdomen, and 
its force may be suggestive of aneurism of the abdomi- 
nal aorta. Pulsation of the liver may be obtained when 
there is no jugular pulse nor notable turgescence of the 
cervical veins. 

Pulmonic Lesions. — As compared with aortic lesions, 
these are of infrequent occurrence, and they are gener- 
ally congenital. Lesions giving rise to a pulmonic 
direct murmur may be localized by differentiating this 



FATTY DEGENERATION OF THE HEART. 251 

murmur from the aortic direct murmur (vide page 234). 
It is to be considered that an inorganic pulmonic direct 
murmur is not infrequent. Pulmonic regurgitant lesions 
can only be diagnosticated by determining that a mur- 
mur is produced at the pulmonic and not at the aortic 
orifice (vide page 235). 

Fatty Degeneration, Myocarditis, and Softening of the 
Heart. — Fatty degeneration of the heart is not repre- 
sented by any distinctive signs, but, nevertheless, the 
physical diagnosis, taking into account the clinical his- 
tory, may be quite positive. The signs are those which 
denote persistent muscular weakness of the heart. The 
apex-beat, if appreciable, is feeble. The intensity of 
the heart-sounds is diminished, and especially the inten- 
sity of the systolic sounds. The sound of impulsion 
and even the mitral valvular sound may be suppressed 
over the apex. The sound of impulsion is especially 
impaired or lost, the systolic sound which is heard being 
chiefly or exclusively the mitral valvular sound. This 
sound is short and valvular, in quality like the diastolic 
sound. Now these evidences of weakened muscular 
power may occur when the weakness is merely func- 
tional, and when the heart is enlarged by predominant 
dilatation. But functional weakness is generally tran- 
sient, and is sufficiently explained by the existence of 
other than cardiac disease. Enlargement by dilatation 
is readily determined by physical signs. If the heart 
be but little, or not at all, enlarged, and pathological 
conditions adequate to explain diminished muscular 
power irrespective of cardiac disease be excluded, and 
at the same time the signs are connected with diagnostic 
symptoms, the existence of fatty degeneration may be 
determined with much confidence. 



252 DISEASES OF THE HEART. 

Fatty degeneration may coexist with valvular lesions 
and enlargement of the heart. The physical diagnosis 
of fatty degeneration under these circumstances is not a 
simple problem. A probable diagnosis may be made 
when the amount of enlargement seems insufficient to 
account for the signs denoting muscular weakness of the 
heart, and when symptoms belonging to the clinical his- 
tory point to fatty degeneration. 

Softeuing of the muscular structure of the heart, 
occurring in myocarditis, in continued fever, and other 
general diseases, is denoted by the same signs which are 
embraced in physical diagnosis of fatty degeneration, 
the most marked evidence being notable weakness ot 
the systolic valvular sounds, and especially weakness or 
suppression of the sound of impulsion. 

Endocarditis. — The physical diagnosis of endocarditis 
relates especially to its occurrence in connection with 
articular rheumatism. The diagnostic sign is a mitral 
systolic non-regurgitant murmur (vide page 196). The 
presence of this murmur, however, in a case of rheuma- 
tism, is not positive proof of an existing endocarditis, 
more especially if the patient have previously had 
articular rheumatism, because an endocarditis developed 
in a previous attack may have left a permanent murmur. 
If the murmur be a mitral regurgitant murmur, and 
the heart be enlarged, it is quite certain that endocar- 
ditis has previously occurred. The positive proof is the 
production of the murmur during an attack of rheuma- 
tism, when previous examinations, made after the com- 
mencement of the rheumatic attack, had shown that 
there was no mitral murmur. An aortic direct murmur, 
in cases of rheumatism, is not evidence of endocarditis, 



PERICARDITIS. 258 

because in many cases of rheumatism this murmur 
occurs and is to be regarded as inorganic. 

In the variety of endocarditis known as ulcerative, 
occurring in the course of infectious or septic diseases, 
and sometimes without any known pathological connec- 
tion, an aortic murmur may be developed, with or 
without a coexisting mitral murmur, owing to the soft 
masses present on the valves. 

Endocarditis is probably of frequent occurrence as 
secondary to mitral and aortic valvular lesions ; but, 
under these circumstances, a physical diagnosis is 
impracticable. 

Pericarditis. — The physical diagnosis of pericarditis 
in the first stage, that is, prior to the effusion of liquid, 
is to be based on a pericardial friction murmur. For- 
tunately for diagnosis, this murmur is uniformly present. 
Its characters as contrasted with endocardial murmurs 
have been stated {vide page 205). The presence of a 
pericardia] friction murmur, in connection with symp- 
toms denoting pericarditis, renders the diagnosis quite 
positive. There is, however, one liability to error. In 
some cases of pleurisy or pneumonia with pleuritic 
inflammation, the movements of the heart occasion a 
rubbing together of the roughened pleural surfaces, and 
in this way a cardiac pleural friction murmur is pro- 
duced. This may be single or double, and when double, 
it simulates the murmur produced within the pericardial 
sac. It is limited to the border of the heart, and is 
neither accompanied nor followed by pericardial effusion. 
Of course, the error of mistaking a cardiac pleural fric- 
tion murmur for one produced within the pericardium, 
can only occur when pleurisy exists, either as a primary 
affection or as secondary to pneumonia. 






254 DISEASES OF THE HEART. 

In the second stage of pericarditis, that is, after the 
effusion of liquid has taken place, the pericardial fric- 
tion murmur often, but not always, disappears. The 
physical diagnosis in this stage is then to be based on 
the signs which show the presence of a greater or less 
quantity of liquid within the pericardial sac. The signs 
which denote pericardial effusion, and its amount, have 
been stated (vide page 211). With a moderate effusion, 
the apex of the heart is raised, and the apex-beat may 
be felt in the fourth intercostal space, and removed to 
the left of its normal situation. With considerable or 
large effusion, the apex- beat is lost, and the sounds of 
the heart are feeble and distant. The sound of impul- 
sion is lost, leaving the mitral and tricuspid sounds, 
which are short and valvular like the diastolic sounds. 

Increase or diminution of liquid in the second stage 
of pericarditis is readily determined by signs obtained 
by percussion and auscultation. When the quantity is 
much diminished, the friction murmur, if it have been 
suppressed, returns, and persists until the pericardial 
surfaces become agglutinated. Not infrequently, by 
auscultating when the body of the patient is inclined 
forward, a friction murmur may be heard, notwithstand- 
ing the pericardial sac contains a large quantity of 
liquid. 

In cases of chronic pericarditis with very large effu- 
sion, dilatation of the pericardial sac is shown by signs 
obtained by percussion and auscultation. There is no 
apex impulse, the heart-sounds are feeble and distant, 
the systolic sounds being short and valvular, and the 
praecordia may be notably projecting. 

A malignant morbid growth filling the pericardial sac 
and inclosing within it the heart, may give rise to all 






FUNCTIONAL DISORDERS. 255 

the signs of pericardial effusion. A case of this kind, 
in a young subject, has fallen under my observation. 

With reference to diagnosis, the etiological relations 
of pericarditis should be kept in mind. These are acute 
articular rheumatism, Bright's disease, tuberculous affec- 
tions, and either pleurisy or pneumonia. It rarely 
occurs in other connections, and, as an idiopathic affec- 
tion, it is extremely rare. 

The presence of air and liquid within the pericardial 
sac gives rise to loud splashing sounds which, occurring 
when respiration is suspended, and when pneumo-hydro- 
thorax is excluded, are at once diagnostic of pneumo- 
hydropericardium. 

Functional Disorders. — Of the varied forms of func- 
tional disorder of the heart, some are rare, and others are 
of frequent occurrence. A rare form is persistent fre- 
quency of the heart's action, the pulse being from 100 
to 120 or more per minute, for weeks, months, and even 
years. This form of disorder exists in the affection 
known as exophthalmic goitre, Graves's or Basedow's 
disease. It occurs, also, without being associated with 
either prominence of the eyes or enlargement of the 
thyroid body. In a rare form, the opposite of this, the 
action of the heart is abnormally infrequent, the pulse 
falling to 50, 40, 30, or less, per minute, the infre- 
quency not being an idiosyncrasy, either congenital or 
acquired, and continuing for a limited period. The 
occurrence with every alternate revolution of the heart 
of a ventricular systole so feeble as not to be represented 
by a radial pulse, is another rare form, and another is a 
want of synchronism in either the contraction of the two 
ventricles, or of the recoil of the coats of the aorta and 
the pulmonic artery, giving rise to reduplication of 



256 DISEASES OF THE HEART. 

heart-sounds (vide page 216). In the more common 
forms, the disorder occurs in paroxysms which are 
variable in duration and in the frequency of their 
occurrence, the heart, in the paroxysms, beating irregu- 
larly, and often with intermissions, the action in some 
instances being violent and in other instances feeble or 
fluttering. These common forms are embraced under 
the name palpitation. 

As regards the physical diagnosis, all the forms of 
disorder are in the same category ; in all the functional 
character of the affection is determined by exclusion, 
inflammatory affections and lesions beiug excluded by 
the absence of their diagnostic signs. In whatever way 
the action of the heart is disturbed, however great may 
be the disturbance, and let it be attended with ever so 
much distress or auxiety, if physical exploration furnish 
no evidence of endocarditis, pericarditis, valvular lesions, 
enlargement of the heart, fatty degeneration, or heart- 
clot, the affection is to be considered as functional. If 
purely functional, the affection is unattended by danger, 
and is generally remediable, at least in the common 
forms. Hence, the very great importance of a positive 
diagnosis. 

In one point of view, the physical diagnosis in func- 
tional disorders may be said to rest, not on negative, but 
on positive evidence. Percussion and auscultation 
afford the means, not only of excludiug inflammatory 
affections and lesious, but of demonstrating the fact that 
the organ is sound, at least as regards freedom from 
ordinary lesions. That its size is normal, is shown by 
the normal situation of the apex-beat, of the lateral 
boundaries of the praecordia, and of the area of the 



FUNCTIONAL DISORDERS. 257 

superficial cardiac space. That the valves are unaffected, 
is shown by the normal characters of the heart-sounds. 
These positive facts, taken in connection with the ab- 
sence of morbid signs, render the diagnosis certain. 
Moreover, the evidence, positive and negative, is readily 
and quickly obtained. Indeed, the time required for 
reaching a conclusion is so brief, that it is often politic 
to prolong unnecessarily the examination in order that a 
positive assurance of the soundness of the organ may 
have in the mind of the patient the weight which is 
desirable in order to secure relief from anxiety and 
apprehension. 

Functional disorders are not infrequently associated 
with lesions with which they have no essential patho- 
logical connection. A patient with lesions which are 
either innocuous or attended with little, if any, incon- 
venience, may suffer from disturbance of the action of 
the heart produced by causes which are wholly inde- 
pendent of the lesions. There is a liability, in these 
cases, to the error of attributing the disorders to the 
lesions, and thus forming an exaggerated estimate of the 
importance of the latter. To decide how much of the 
disturbed action of the heart is due to a superadded 
functional affectiou, is not as easy as to determine that 
lesions do not exist. The decision must be based on the 
character, degree, or extent of the lesions, as evidenced 
by the physical signs. In this connection may be 
stated a practical maxim which it is well to bear in 
mind whether functional disorders exist or not, namely, 
valvular lesions rarely give rise to much inconvenience 
until they have led to enlargement of the heart; and 
enlargement, either with or without valvular lesions, 
as a rule, docs nut lend to the serious effects which are 



258 DISEASES OF THE HEART. 

characteristic of cardiac disease, so long as the enlarge- 
ment is due to predominant hypertrophy and not to 
dilatation. 

Thoracic Aneurism. 

The physical conditions incident to thoracic aneurism 
which are concerned in the production of signs, are, the 
presence of a tumor within the chest, of variable size, 
formed by the aueurismal sac ; the passage of blood into 
the sac with each ventricular systole, and the expulsion 
of blood in the diastole by the recoil of the coats of the 
aneurism ; the size of the opening into the sac as affect- 
ing the quantity of blood which it receives with each 
systole ; the quantity of stratified fibrin which the sac 
contains ; the point of connection with the aorta of the 
aueurismal tumor, and the direction from this point in 
which the tumor extends, together with its relations to 
the lungs, the trachea, the primary bronchi, the intra- 
thoracic veins, the oesophagus, the recurrent laryngeal 
nerve, the sympathetic nerve, and either the innominate 
or subclavian artery. 

With reference to diagnosis, it is well to bear in mind 
that, in the great majority of cases, an aortic aneurism 
is connected with either the ascending portion, or the 
junction of the ascending and the transverse portion of 
the arch, aud that the tumor generally extends to the 
right in a lateral or antero-lateral direction. The physi- 
cal diagnosis is more easily made when the aneurismal 
tumor is thus connected. The signs are less available 
if the aneurism arise from the transverse or descending 
aorta, aud especially if the tumor extends in a direction 
downward or backward. 



THORACIC ANEURISM. 259 

An aneurismal tumor which has made its way through 
the walls of the chest, or which, without perforation, 
causes a circumscribed bulging obvious to the eye and 
touch, presents the following diagnostic signs : An im- 
pulse is seen and felt which is synchronous with the 
ventricular systole. The force of the impulse is varia- 
ble, depending, aside from the force with which the left 
ventricle contracts, upon the size of the orifice between 
the sac and the artery, and the quantity of fibrin which 
the sac contains. A vibration or thrill with each im- 
pulse is sometimes a marked sign, but is often wanting. 
Frequently, but by no means constantly, a systolic mur- 
mur is heard over the tumor, and there may be also a 
diastolic murmur produced by the passage of blood from 
the sac. The heart-sounds are transmitted to the tumor 
with more or less increased intensity. There is notable 
dulness on percussion over an area corresponding to the 
space within the chest which the tumor occupies. If 
the tumor be of considerable size, it may produce con- 
densation of lung around it; the area of dulness on per- 
cussion will be in this way extended beyond the limits 
of the tumor. Under these circumstances, bronchial 
respiration and bronchophony may be produced. If the 
aneurismal sac be beneath the integument, there may be 
to the touch a sense of fluctuation. 

With the foregoing signs, the physical diagnosis 
scarcely admits of doubt. Some of the signs may be 
produced by a tumor, not aneurismal, so situated as to 
receive and conduct the aortic impulse. The chances of 
a tumor being so situated as to simulate the signs of an 
aneurism are few. I have met with a case of empyema 
in which perforation of the chest took place in the sec- 
ond intercostal space on the right side of the sternum, 



260 DISEASES OF THE HEART. 

giving rise in this situation to a fluctuating tumor which 
had a strong pulsation. On a superficial examination 
the case seemed clearly one of aneurism ; but an exami- 
nation of the chest showed the right pleural cavity to 
be filled with liquid, and a puncture in the axillary 
region gave exit to a large quautity of pus, the pulsating 
tumor disappearing after a certain quantity of the puru- 
lent liquid had escaped. I have met with a similar 
pulsating tumor, incident to empyema, on the posterior 
aspect of the chest. 

When, from its small size or its situation, an aneuris- 
mal tumor does not come into contact with the thoracic 
wall, and when it is situated beneath the sternum, signs 
obtained by palpation and inspection being absent, the 
physical diagnosis is less easy. Important signs are, 
dulness within a circumscribed space situated in the 
course of the aorta ; an abnormal transmission of the 
heart-sounds within this space, and the presence of mur- 
murs. These signs are not always available, and when 
present they are not sufficient for a positive diagnosis. 
Other physical evidence and the presence of certain 
symptoms render the existence of aneurism highly 
probable either with or without the foregoing signs. If 
an aneurismal tumor press upon the trachea, it occasions 
a tracheal rale, or stridor, together with weakness of the 
respiratory murmur on both sides of the chest. If the 
tumor press upon a primary bronchus, it occasions 
diminished or suppressed respiratory murmur on one 
side, and increased respiratory murmur on the other 
side of the chest. These physical signs should always 
lead to a suspicion of aneurism in a person forty years 
of ao-e. Symptoms which should excite this suspicion 
and lead to careful physical exploration for the physical 



THORACIC ANEURISM. 261 

signs of aneurism, are dyspnoea from spasm or paralysis 
of the muscles of the glottis, and aphonia or impairment 
of the voice without evidence of laryngitis, these symp- 
toms denoting either excitation or pressure of the. recur- 
rent laryngeal nerve ; dysphagia from pressure upon 
the oesophagus ; congestion of the face, neck, and upper 
extremities from obstruction of the vena cava or the 
vense innominatae ; inequality of the radial, carotid, and 
subclavian pulsation on the two sides, or the absence of 
pulsation on one side, and contraction of one of the 
pupils. These symptoms not only render probable the 
existence of aneurism, but indicate its situation as 
regards the aorta and the direction in which the aneu- 
rismal tumor extends. 

An aneurism may be suspected when, owing to 
shrinkage of the lung, or deformity of the chest, either 
the aorta or the pulmonary artery just above the heart 
is removed laterally from its normal situation or brought 
into contact with the walls of the chest in the second 
intercostal space, so as to give rise to an appreciable im- 
pulse. A murmur may also be present at the point of 
impulse. An error of diagnosis under these circum- 
stances is avoided by finding an adequate explanation of 
the signs just noted, and by the absence of other signs 
and of symptoms which are diagnostic of aneurism. 

In conclusion, an aortic murmur, however intense or 
rough, is never evidence of aortic aneurism ; and, on 
the other hand, the absence of murmur is by no means 
sufficient for the exclusion of aneurism. 



NDEX 



A BSCESS of lung, 23, 25, 176 
J\ Adventitious respiratory 
sounds or rales, 117 
cavernous, 128 
classification of, 117 
crepitant, 23, 125, 164 
dry bronchial, 123, 151, 

156 
gurgling, 128 
indeterminate, 133 
laryngeal and tracheal, 

117 
metallic tinkling, 131, 

145 
moist bronchial, 118, 

152, 154 
pleural or friction, 21, 

129, 163, 253 
sibilant and sonorous, 

124, 156 
splashing or succussion, 

129, 132, 171, 255 
subcrepitant, 119, 120, 
121 
^Egophony, 136, 165 
Air in pleural space, 21 
Amphoric resonance, 69 

conditions causing, 69 
respiration, 111 
voice, 142 
whisper, 142 
Analysis of sounds, 32 
Aneurism, thoracic, 25, 26, 239, 

258 
Aorta and pulmonary artery, re- 
lations of, to chest-walls, 198 
Aortic direct murmur, 228, 248 
diastolic non -regurgitant 

murmur, 230, 248 
lesions, diagnosis of, 248 
regurgitant murmur,230,249 



Apex-beat of heart, modification 

of, 195, 196, 208, 240-243 
Apoplexy, pulmonary, 63, 177 
Artery, pulmonic, and aorta, 
relation of, to walls of chest, 198 
Asthma, 24, 124, 155 
Atrophy, senile, of lungs, 157, 

161 
Auscultation, definition of, 14, 71 
in disease, 94 
in health, 73, 78 
mediate and immediate, 74 
position for, 77 
rules in practice of, 76 

BASEDOW'S disease, 255 
Blood currents, aortic, 219, 
220 
direct, 218, 221 
mitral, 218 
pulmonic, 221 
regurgitant, 219 
relation of, to heart 

sounds, 219 
tricuspid, 221 
Bread, use of, to imitate pul- 
monary signs, 46, 67, 68 
Bronchi, obstruction of, 24, 27 
Bronchial rales, dry, 123, 151, 156 
moist, 118, 152, 154 
respiration, 101 
causes, 101 
whisper, increased, 139 
normal, 91 
Bronchitis seated in large bron- 
chial tubes, 23, 150 
in small bronchiul tubes 
(capillary), 24, 152 
Broncho-cavernous respiration, 

109 
Bronchophony, 134, 165 



264 



INDEX, 



Bronchophony whispering, 13G, j 

139 
Broncho-pneumonia, 154 
Bronchorrhcea, 23, 120 
Broncho-vesicular respiration, 

103 
Bruit de diable, 229 

CAPILLAKY bronchitis, 152 
Carcinoma of lung, 22, 25, 
181 
Cardiac space, superficial and 

deep, 51, 160, 195, 197 
Cavernous rale, 128 
respiration, 106 

imitation of, 108 
Cavities, pulmonary, 25,27,185, 

191 
Chest, anatomy and physiology 
of, 16, 198 
regional divisions of, 34, 49, 
82 
Cirrhosis of lung, 192 
Clicking rale, 125 
Clogged-wheel respiration, 115 
Collapse of lung, 22, 152 
Conditions, morbid physical, in- 
cident to different dis- 
eases of the respira- 
tory system, 20, 148 
summary of, 26 
physical, of the heart in dis- 
ease, 194, 206 
in health, 195, 196 
represented by amphoric 
resonance, 69 
by cracked-metal reso- 
nance, 70 
by dulness, 64 
by flatness on percus- 
sion, 62 
by tympanitic reso- 
nance, 66 
by vesiculotympanitic 
resonance, 68 
Congestkn, hypostatic, of lungs, 

oedema in, 181 
Coughing, signs obtained by, 

145 
Cracked-metal resonance, 70 

imitation of, 71 
Crepitant rale, 23, 125, 164 



DEATH-EATTLES, 117 
Diaphragmatic hernia, 192 
Diseases of the respiratory sys- 
tem, physical conditions inci- 
dent to, 20, 145 
Dulness, 64 

conditions causing, 64 
hepatic, 52, 54 
Dulness, tympanitic, 66, 190 
Duration of sounds, 32 
Dysphagia, in thoracic aneu- 
rism, 261 

ECHO, amphoric, 142 
Emphysema, diagnosis of, 
161 
pulmonary or vesicular, 
22, 26, 68, 112, 153, 
154, 155, 157 
interlobular, 22 
rhythm of respirations 
in, 159 
Empyema, 21, 162, 167 

pulsating, 168 
Endocardial murmurs, 218, 237 
Endocarditis, diagnosis of, 252 
Exocardial murmur, 218, 237 
Expiratory sound, prolonged, 113 
Exploration, physical, different 

methods of, 13 
Exudation in air-vesicles, 23, 26 

I ASSURES, interlobar, 18, 40, 
^ 41 
Flatness, 62 

conditions causing, 62 
hepatic, 52, 54 
Fremitus, diminished, 144 
increased, 137, 139 
in different regions, 88 
normal, vocal, 86 
suppressed, 144 
Friction murmur, pericardial, 
218, 237 
pleuritic, 21, 129, 163, 253 

GANGPvENE, pulmonary, 22, 
25, 178 
Glottis, oedema of, 148 
paralysis of, 148, 261 
spasm of, 148 
Goitre, exophthalmic, 255 






265 



Graves's disease, 25 
Gurgling rale, 128 



H 



EAET, abnormal impulses of, 
208 
anatomical relations of, 194 
apex-beat of, 19, 195, 196, 

208, 240, 241, 243 
diagnosis of diseases of, 240 
dilatation of, 207 
enlargement of, 206, 240 
fatty degeneration and soft- 
ening of, 208, 251 
first sound of, intensified, 
212 
weakened, 213 
functional disorders of, 255 
hypertrophy of, 207 
hypertrophy and dilatation 
of, 239 
signs of, 240, 244, 245 
inflammation of, 251, 252 
murmurs of, 184, 199, 217, 

237 
normal, 240 
palpitation of, 256 
physical conditions of, in 
disease, 194, 206 
in health, 194, 195 
second sound, aortic, weak- 
ened, 214 
pulmonic, weak- 
ened, 214 
softening of, 251 
sounds of, 194, 199 

abnormal modifications 
of, 212, 214 
transmission of, in 
phthisis, 189 
five in number, 205 
mechanism of, 201, 102 
mitral systolic, 204, 205 
reduplication of, 216, 

255 
tricuspid systolic, 204, 
205, 215 
valvular lesions of, 209, 245 
aortic, 245 
mitral, 240 
pulmonic, 250 
tricuspid, 250 



Hemorrhagic infarctus, 22, 63, 

177 
Hernia, diaphragmatic, 25, 27, 

192 
Hum, venous, 229 
Hydatids of lung, 22 
Hydrothorax, 21, 162, 168 

rNDETERMINATE rales, 133 
i Infarctus, hemorrhagic, 22, 

63, 177 
Inspiratory sound shortened, 112 
Intensity of normal and abnor- 
mal sounds, differences of, 27, 
28, 45, 65 
Interrupted respiration, 115 
Interstitial pneumonia, 192 



JERKING respiration, 115 



T ARYNGEAL and tracheal 
Jj respiration, 79 

rales, 117 
voice, 85 
Laryngismus stridulus, 148 
Larynx, foreign bodies in, 149 
and trachea, affections of, 

27, 148 
tumors of, 149 
ulcers of, 149 
Lesions, valvular, of heart, 209, 
245 
diagnosis of, 245 
Liquid, in chest, 20, 23, 26, 62 
Liver, dulness over, 52, 54 

flatness over, 52, 54 
Lobular pneumonia, 22, 152, 154 
Lobules, pulmonary, collapse of, 

22, 152 
Lung, solidification of, 21, 26, 
33, 104, 138, 139 

METALLIC tinkling, 1 29, 1 31 , 
145, 170 
-Mitral lesions, diagnosis of, 245 
Mitral murmurs, direct, 222 
diastolic, 225 
regurgitant, 226 
presystolic, 222 



266 



INDEX. 



Mitral systolic non-regurgitant 

or intra-ventricular, 226 
Murmur, aortic direct, 228, 231 
232, 238 
aortic prediastolic, 230 
cardiac, 194, 199, 210, 217, 

222, 237 
cardiac pleural, 227, 253 
diastolic or non-regurgilant, 

230 
endocardial, 218, 237 

coexisting, 231 
exocardial, 218, 237 
mitral diastolic, 226, 246 
presystolic, 222, 246 
mechanism of, 222 
without mitral lesions, 

223, 224, 246 
limits of, 224 
thrill with, 225 
mitral direct, 222 

regurgitant, 226, 246 
mitral systolic, non-regurgi- 
tant, or intra-ventri- 
cular, 226, 240 
causation, 226, 246 
normal vesicular, 80 

in different regions, 83 
pericardial or friction, 218, 

237 
pulmonic direct, 234 
regurgitant, 235 
regurgitant, 230 
tricuspid direct, 233 
regurgitant, 244 
vesicular diminished, 96 
causes, 99 
increased, 95 
suppressed, 99 
Murmurs, endocardial, 218, 221 
exocardial, 218, 237 
facts relating to, 236 
groups of, 217 
basmic, 217 

organic and inorganic, 217 
Myocarditis, 251 



r[?DEMA, pulmonarv, 23, 26, 
UL 62, 127, 153, 179" 
Organs, respiratory, anatomy and 
physiology of, 16 



PALPITATION, cardiac, 256 
Pectoriloquy, 142 
Percussion, analysis of sounds 
in, 45 
definition of, 14 
in health, 42 
in disease, 61 
instruments for, 45 
modes of performing, 44 
objects of, 45 
position for, 58, 59 
respiratory, 57 
rules in practice of, 58 
sense of resistance in, 71 
signs of disease furnished 
by, 61 
Percussors, 44 

Pericardial or friction murmur, 
218, 237, 253 
sac, liquid within, 210 
surfaces, roughness of, 210 
Pericarditis, chronic, 254 

diagnosis of, 253 
Phthisis, 22, 23, 25, 108, 184 
advanced, 185, 191 
differential diagnosis of, 189 
fibroid, 192 
groups of cases in, 184 
incipient, 184, 187, 189 
moderate, 185 

signs of, direct and acces- 
sory, 186 
Pitch of normal and abnormal 

sounds, 28, 45 
Pleural rales, 21, 129, 163, 253 
Pleurisy, acute and chronic, 21, 
26, 34, 162 
signs of first stage of, 163 
friction sound in, 163 
signs of second stage of, 164 
horizontal and S-shaped 
lines in, 164 
Pleurisy, chronic, signs of, 166 
Pleuro-pneumonia, 172 
Pleximeters, 45 

Pneumonia, acute lobar, 23, 171 
circumscribed, 177 
crepitant rale in, 172, 176 
embolic, 22, 177 
interstitial, 22, 192 
lobular, 22, 152, 154 
signs of abscess in, 177 



267 



Pneumonia, signs in first stage, 
172 
signs of purulent infiltration 

in, 176 
signs in second stage, 172 
signs in third stage, 175 

Pneumo-hydropericardium, 255 
hydrothorax, 21, 26, 169 
amphoric voice in, 170 
metallic tinkle in, 170 

Pneumo-pyothorax, 169 

Pneumorrhagia, 23, 178 

Pneumothorax, 21, 26, 108, 169 

Prsecordia, 195, 406 

Pulmonary apoplexy, 177 
gangrene, 22, 25, 178 
oedema, 23, 26, 62, 127, 153, 
179 

Pulmonic direct murmur, 234 
lesions, diagnosis of, 250 
regurgitant murmur, 235, 
250 . 

Pupils, inequality of, in thoracic 
aneurism, 261 

Pyothorax, 21 

QUALITY of normal and ab- 
normal sounds, 27, 29, 45 
terms denoting, 31 

RALE, cavernous or gurgling, 
125, 128 
crepitant or vesicular, 23, 

125 
indeterminate, 133 
metallic tinkling, 131, 145 
splashing or succussion, 129, 

132, 171, 255 
Kales, 117 

fine bubbling or subcrepi- 

tant, 118, 119, 120 
classification of, 117 
dry bronchial, 123, 151, 156 
laryngeal and tracheal, 117 
moist broncbial, 118, 152, 

154 
pitch of, 23 
pleural or friction, 21, 129, 

163, 253 
tracheal, 23, 117 
sibilant and sonorous, 124, 

156 



Kegions, anatomical relations of, 
39 
division of chest into, 34 
sections of chest correspond- 
ing to, 35, 49, 82 
Kesistance, sense of, in percus- 
sion, 71 
Eesonance, absence of, or flat- 
ness, 62 
amphoric, 69 
cracked metal, 70 
diminished, or dulness, 64 
disparity of, oh the two 

sides, 55 
in different regions, 49 
normal, vesicular, on per- 
cussion, 46 
vocal, over larynx and 
trachea, 85 
over chest, 86 
standard for, 55 
tympanitic, 47, 48, 66 
variations in different re- 
gions of chest, 49 
vesiculo-tympanitic, 68, 158 
vocal, diminished, 143 
increased, 137 

causes of, 138 
Eespiralion, abnormal modifica- 
tions of, 95 
amphoric, 111 

imitation of, 111 
bronchialor tubular, 101,259 
broncho-cavernous, 109 
broncho-vesicular, 103 
cavernous, 106 
diminished, 96, 149, 154, 159 
harsh, 103 
indeterminate, 103 
in different regions, 83 
interrupted, 115 
metamorphosing, 110 
normal, laryngeal, and tra- 
cheal, 79 
vesicular murmur of, 80 
puerile, 96 
rude, 103 

supplementary, 96 
suppressed, 99 
vehicular murmur of, in- 
creased, 95 
vesiculocavernous, 110 



■Hi* 



Respiratory organs, anatomy 
and physiology of, 16 
physical conditions in- 
cident to diseases of, 
20, 26, 147 
Rhythm, respiratory, 19 
in emphysema, 159 

OIGNS, 14 

U by percussion in disease, 60 
in health, 43 
healthy and morbid, dis- 
tinctive characters of, 14, 
27 
object of, 15 

obtained by coughing, 145 
physical, definition of, 14 
respiratory, in disease, 94, 99 
classification of, 95 
in health, 73 
significance of, 33 

as representing physical 
conditions, 33 
vocal, in health, 80 
of disease, 133 
Softening of the heart, 251 
Sounds, differences of intensity 
in, 27, 28 
in pitch, 29 
in quality, 29 
normal and abnormal, 14,95 
rhythm of, 32 
Spleen, 53 
Splashing or succussion sounds, 

129, 132, 171, 255 
Stethoscope, advantages of, 74 
binaural, 74 
Hawksley's, 76 
Stomach, 53 

THOBACIC aneurism, 258 
diagnosis of, from em- 
pyema, 259 
Thrill, with mitral presystolic 
murmurs, 225 
with thoracic aneurism, 259 
Thymus gland, 53 
Tinkling, metallic, 131, 145, 170 
Trachea, affections of, 27, 148 
Tracheal respiration, 79 
Tricuspid direct murmur, 233,250 
lesions, diagnosis of, 250 



Tiicuspid regurgitant murmur, 
233, 250 
safety-valve function of, 221 
Tuberculosis, acute, 154, 183 
Tubular respiration, 101 
Tumor within the chest, 25, 27, 

63, 190, 254 
Tussive signs, 145 

significance of, 146 
Tympanitic dulness, 66, 190 
resonance, 39, 47, 66 

conditions causing, 66 

VALVULAR cardiac lesions, 
209, 245 
aortic, 248 
mitral, 246 
pulmonic, 250 
tricuspid, 250 
Venous hum, 229 
Vesicular rale, 125 

resonance, normal, 46, 47 
Vesiculocavernous respiration, 

110 
Vesiculo-tympanitic resonance, 
68, 158 
conditions causing, 68 
Vocal fremitus, diminished or 
suppressed, 144 
normal, 86, 88 
increased, 137, 139 
resonance, diminished and 
suppressed, 143 
normal, 85, 86 

indifferent regions, 
88 
increased, 136, 137 
signs of disease, 133 
Voice, abnormal, 134 
amphoric, 142 
laryngeal and tracheal, 85 
normal, 86, 88 

WAVY respiration, 115, 187 
Whisper, amphoric, 1,42 
bronchial, increased, 139 
cavernous, 140 
in different regions, 92 
laryngeal or tracheal, 91 
normal bronchial, 91 
Whispering pectoriloquy, 141 



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